European Journal of Preventive Cardiology

To establish the effects of relaxation therapy on the recovery from a cardiac ischaemic event and secondary prevention.

A search was conducted for controlled trials in which patients with myocardial ischaemia were taught relaxation therapy, and outcomes were measured with respect to physiological, psychological, cardiac effects, return to work and cardiac events. A total of 27 studies were located. Six studies used abbreviated relaxation therapy (3 h or less of instruction), 13 studies used full relaxation therapy (9h of supervised instruction and discussion), and in eight studies full relaxation therapy was expanded with cognitive therapy (11 h on average). Physiological outcomes: reduction in resting heart rate, increased heart rate variability, improved exercise tolerance and increased high-density lipoprotein cholesterol were found. No effect was found on blood pressure or cholesterol. Psychological outcome: state anxiety was reduced, trait anxiety was not, depression was reduced. Cardiac effects: the frequency of occurrence of angina pectoris was reduced, the occurrence of arrhythmia and exercise induced ischaemia were reduced. Return to work was improved. Cardiac events occurred less frequently, as well as cardiac deaths. With the exception of resting heart rate, the effects were small, absent or not measured in studies in which abbreviated relaxation therapy was given. No difference was found between the effects of full or expanded relaxation therapy.

Intensive supervised relaxation practice enhances recovery from an ischaemic cardiac event and contributes to secondary prevention. It is an important ingredient of cardiac rehabilitation, in addition to exercise and psycho-education.

We analysed data collected during a nationwide cross-sectional household survey to estimate the prevalence of and identify factors associated with smoking in Pakistan.

Population-based, cross-sectional survey [National Health Survey of Pakistan (NHSP) 1990–1994].

A population-based survey was carried out in Pakistan during 1990–1994. A nationally representative sample of 18 135 individuals aged 6 months and older was surveyed. We restricted this analysis to individuals aged 15 years or older (n = 9442). The main outcome measure was self-reported smoking. Smokers were defined as individuals who reported current smoking and having smoked at least 100 cigarettes or ‘beddies’ during their lifetime.

Overall prevalence of smoking was 15.2% [95% confidence interval (CI), 14.5–15.9%]. It was 28.6% (27.3–29.9%) among men and 3.4% (2.9–3.9%) among women. The highest prevalence was reported in men aged 40–49 years (40.9%). The independent predictors of smoking identified in the multivariate logistic regression analysis included age, male gender, ethnicity and illiteracy.

One out of every two to three middle-aged men in Pakistan smoke cigarettes. Our findings suggest that ethnically sensitive smoking control programmes that include measures for improving literacy rates are needed in Pakistan.

Data on the recent evolution in coronary heart disease (CHD) mortality and incidence rates are lacking in France. This paper aims to investigate whether the declining trends observed from 1985–1993 still persist in the second half of the 1990s.

Population registers of acute CHD have been implemented in three specific geographical areas, first as part of the MONICA Project (1985–1993) and, since 1997, according to a simplified registration procedure. Weighted Poisson regressions have been used to investigate time trends in CHD events in men and women aged 35–64 after correction for registration differences.

Data obtained from 1997–2000 showed that the north-to-south gradient of decreasing frequency of CHD events in France was still present. Besides, they revealed no specific trend in CHD morbidity by centre and gender, except in Lille (in the north of France) where events tended to increase in women. Coronary heart disease mortality rates in recent years were decreasing in men, particularly in the north and east of France, but were stable in women with, even, a rising tendency in the north.

The decreasing trend in CHD events in France observed from the mid 1980s to the early 1990s seemed to markedly slow down in the second half of the 1990s.

Fitness and obesity are both independently associated with cardiovascular events and mortality. C-reactive protein (CRP), a predictor of cardiovascular events is associated with obesity; but its association with cardiorespiratory fitness in early adulthood is uncertain. The aim of this study was to examine the relationship between cardiorespiratory fitness and CRP, controlling for obesity in an unselected cohort of young adults.

A cross-sectional study in a representative birth cohort.

We measured CRP levels, cardiorespiratory fitness, anthropometric variables, blood pressure and smoking in 26-year-old men (n=400) and women (n=315). Log CRP levels were compared across cardiorespiratory fitness with adjustment for body mass index (BMI), sex, blood pressure, smoking and combined oral contraceptive use.

Geometric mean CRP levels were higher in women (3.23 mg/l, 95% CI 2.85–3.64) compared with men (1.70mg/l, 1.52–1.89). Regression analysis adjusting for sex and weight showed an inverse association between fitness and CRP (β= −0.16, P<0.001). This association held after statistical controls were added for BMI, systolic blood pressure and smoking and combined oral contraceptive use (P ≤ 0.01).

Cardiorespiratory fitness levels are inversely associated with CRP levels in young adults independent of obesity, blood pressure, smoking and combined oral contraceptive use in women. Physical fitness may decrease the risk of cardiovascular events by reducing inflammation.

Three haptoglobin phenotypes exist called Hp 1-1, Hp 2-2, and Hp 2-1. Patients carrying the haptoglobin 1 allele seem to be partly protected against coronary artery disease. An attenuated heart rate variability is associated with a poor outcome in patients with coronary artery disease. Therefore, we hypothesized that the presence of the haptoglobin 1 allele would be associated with a favourable heart rate variability. Design A cross-sectional study.

We included 255 patients who were referred for elective coronary angiography as a result of suspected coronary artery disease, and all underwent 24-h electrocardiogram recordings to assess heart rate variability in the time domain. The haptoglobin phenotype was also determined in each patient.

There were 159 patients in the Hp 1-1 and Hp 2-1 groups and 98 patients in the Hp 2-2 group. The two groups were comparable with respect to clinical parameters. However, the Hp 2-2 group had significantly lower 24-h heart rate variability values compared with the other group (RR 882 versus 921 ms, P=0.02; RMSSD 26 versus 30 ms, P<0.01; pNN50 6 versus 9%, P=0.01). Furthermore, Hp 2-2 was independently and negatively associated with heart rate variability (P=0.02).

Hp 2-2 was associated with an attenuated heart rate variability in patients with coronary artery disease that may help to explain other results reporting a poor prognosis in Hp 2-2 patients.

Physical training is recommended as an efficient therapy in patients with chronic heart failure (CHF). Low-frequency electrical myostimulation (EMS) has recently been suggested as a good alternative to conventional aerobic training. The aim of this study was to compare the effects of EMS and conventional exercise training in patients with moderate to severe CHF.

Twenty-four patients with stable CHF (56.7±7.3 years, New York Heart Association grades II and III) underwent 5 weeks of exercise training, 5h a week, using EMS (n=12) or conventional (n=12) training programmes. At baseline and after the training period, patients performed a symptom-limited cardiopulmonary test, a 6-min and a 200-m walk exercises and an evaluation of maximal knee extensor strength.

Oxygen uptake (VO₂) and workload at the end of exercise (peak values) and at ventilatory threshold increased after EMS (P ≤ 0.05) and conventional exercise (P<0.05) training programmes. The slope of the relationship between VO₂ and workload was reduced after EMS (P<0.05). The time to recover half of peak VO₂ decreased irrespective of the training programme (P<0.001). EMS and conventional exercise training programmes also increased the maximal knee extensor strength (P<0.05), the distance walked in 6 min (P<0.01) and decreased the time elapsed to cover 200 m (P<0.05). These improvements were not statistically different between EMS and conventional exercise.

In patients with moderate to severe CHF, 5 weeks of EMS and conventional exercise training produce similar improvements to exercise capacity and muscle performance.

With the implicit purpose of identifying relevant intervention targets, the aim of the study was to test if lifestyle factors associated with obesity are unevenly distributed across social groups, and whether an uneven distribution of such factors may contribute to the explanation of social differences in obesity.

Cross-sectional study of 3290 men aged 53-75 years (mean = 63) carried out in 1985-1986 using in addition, data from a previous baseline established in 1970-1971. Information about lifestyle factors was obtained from a questionnaire validated during an interview. Potential risk factors were smoking history, alcohol consumption, leisure time physical activity (LTPA), and from the 1985-1986 study only: consumption of tea and coffee, use of sugar in tea or coffee, and avoidance of fat in foods. The clinical examination included measurements of height and weight. Obesity was defined as a body mass index ≥30 (BMI = kg/m²). Based on information about education and job profile the men were subdivided into five social classes.

Overall, 291 men (8.8%) were obese. The lower the social class the higher the proportion of obese men: in social classes I and II, 4.5% (of 953), social class III, 9.1% (of 636), social class IV, 11.1% (of 1353), and social class V, 11.6% (of 346), P< 0.001 (trend test). Leisure time physical activity, alcohol consumption, smoking habits, use of sugar in hot beverages, and consumption of coffee and tea, were all significantly associated with obesity, either positively or negatively, and even significantly associated with social class. Based on these lifestyle factors it was possible to discriminate subgroups with highly different prevalences of obesity. Despite this, adjustment for identified obesity covariates in a multiple logistic regression analysis did in no way explain the association of social class with obesity.

Lifestyle factors in concert strongly associated with obesity are unevenly distributed across social classes, yet incapable of explaining the higher prevalence of obesity in lower social classes.

To compare rates of blood pressure (BP) control with the level of adherence to antihypertensive treatment and factors influencing compliance in Greek patients.

An observational cross-sectional study on 1000 consecutively treated hypertensive patients, admitted to a University department of general surgery in a Greek hospital.

Patients were interviewed by the same doctor using pre-coded questionnaires with questions on demographic data, health and treatment status. Blood pressure was measured using a standard mercury sphygmomanometer. Treatment of hypertension was defined as current use of antihypertensive medication. Compliance was defined as an affirmative reply to a number of questions regarding regular use of antihypertensive medication according to the physician's instructions.

Satisfactory BP control (levels <140/90 mmHg) was documented in only 20% of the treated hypertensives. Compliance to antihypertensive treatment was found in only 15% of the patients. Control of BP was positively associated with compliance. Compliance was more common among patients aged <60, city dwellers, the better educated, those more adequately counselled by their physicians and those followed by a private doctor. As regards treatment, compliance was better among those taking one antihypertensive tablet per day, those who had never changed their antihypertensive regimen and those who had never changed their doctor.

Compliance is associated with more effective BP control. Physicians can enhance patient compliance and hypertension control by devoting more time to counselling, avoiding unnecessary changes in drug regimens and restricting the tablet numbers.

Recent guidelines target individuals at highest risk as a priority. However, implementation of guidelines even in this group is sub-optimal.

A multicenter, observational follow-up study.

A total of 5600 consecutive patients ≥55 year with high risk of vascular events were evaluated for risk factors and medication usage and followed for 1 year for primary end-points (death, myocardial infarction, stroke), and secondary end-points (revascularization, hospitalization).

The patients were divided into two groups: those without and with vascular disease. In the first group, mortality at 1 year was significantly higher in those with end organ damage (5.8 versus 2.7%, P= 0.005). Similarly, the mortality in patients with known vascular disease (CAD, peripheral vascular disease, ischaemic stroke) was higher in the presence of a previous vascular event (7.8 versus 5.3%, P=0.055, vascular event: non-fatal MI/stroke). The use of antiplatelets, statins, beta-blockers and angiotensin-converting enzyme inhibitors was low and did not improve in the follow-up period. The most important predictors of cardiovascular mortality were the presence of end organ damage [odds ratio (OR) 1.65, P= 0.001], pre-existing vascular disease (OR 1.49, P= 0.023) and protectively, the consistent use of angiotensin-converting enzyme inhibitors (OR 0.49, P= 0.001).

In a high-risk Turkish population, the early mortality and morbidity due to cardiovascular events was unacceptably high and medical treatment inadequate. The presence of end organ damage and a previous vascular event increased the risk even further and should be vigorously questioned. Aggressive lifestyle modification and medical therapy should be instituted in these patients.

The estimation of population distribution of total cholesterol, as well as other blood lipids requires population surveys. Comparability of the estimates over time or between populations requires a predefined, standardized measurement protocol. This paper will assess the effect of variation in the pre-analytic procedures, on the estimation of population distribution of total cholesterol and the prevalence of hypercholesterolaemia. Implications of variation to real survey results are demonstrated on data collected during the WHO MONICA Project.

The extent (%) of pre-analytic variations were determined by literature review. Simulations were then used to estimate the effect of these variations on the distribution of total cholesterol values. Three populations were selected as examples for different population distributions of total cholesterol levels and variations resulting from seasonal and postural changes, use of tourniquet, and serum versus plasma collection were simulated both individually and in combinations.

Depending on the population distribution of total cholesterol, differences in pre-analytic procedures can explain a difference of up to 1.12 mmol/l in the mean total cholesterol between populations, and a difference up to 41% in the prevalence of hypercholesterolaemia (> 6.5 mmol/l).

Variation in results on measured total cholesterol levels due to differences in procedures during the pre-analytic stage can diminish substantially the reliability and comparability of measurements among surveys over time and between populations. The effect of pre-analytic variation in the population estimates of total cholesterol can be extensively reduced by standardization and training.

We examined the association between smoking, apolipoprotein E (ApoE) genotype, and early onset of coronary heart disease (CHD).

Smoking behaviour and ApoE genotype of 904 patients with CHD aged 30–70 years were assessed with respect to age at onset of CHD.

The adjusted odds ratio for early onset of CHD (< 55 years) was 1.86 (95% confidence interval, 1.31–2.62) for smokers compared to non-smokers. The ApoE genotype had no significant influence and there was no significant interaction between ApoE genotype and smoking.

We found smoking but not ApoE genotype to be an independent risk factor for early onset of CHD.

Studies into social inequalities in health tend to focus more on parental socio-economic status (SES) as it affects the children. We aimed to test the hypothesis that socio-economic inequalities would not affect the casual blood pressure among Nigerian adults.

Resting blood pressure (BP) and pulse rate of 1067 sedentary adults were measured. Rate pressure product and pulse pressure were later calculated. Second, a structured questionnaire, which objectively assessed the SES of the subjects, was administered. Subsequently, a self-rating SES ladder was employed to classify the subjects into different socio-economic groups. This was used as a check for the structured questionnaire. A Pearson product correlation coefficient comparing the two outcome measures revealed a high correlation (r=0.951, P<0.01). Socio-economic status was found to have an inverse significant (P<0.05) effect on systolic pressure, heart rate and pulse pressure. The 95th centile blood pressure obtained was 154/91 mmHg.

Low SES is associated with development of hypertension among the Nigerian adults.