Exercise and Coronary Atherosclerosis: Observations, Explanations, Relevance, and Clinical Management.

Physical activity and exercise training are effective strategies for reducing the risk of cardiovascular events, but multiple studies have reported an increased prevalence of coronary atherosclerosis, usually measured as coronary artery calcification, among athletes who are middle-aged and older. Our review of the medical literature demonstrates that the prevalence of coronary artery calcification and atherosclerotic plaques, which are strong predictors for future cardiovascular morbidity and mortality, was higher in athletes compared with controls, and was higher in the most active athletes compared with less active athletes. However, analysis of plaque morphology revealed fewer mixed plaques and more often only calcified plaques among athletes, suggesting a more benign composition of atherosclerotic plaques. This review describes the effects of physical activity and exercise training on coronary atherosclerosis in athletes who are middle-aged and older and aims to contribute to the understanding of the potential adverse effects of the highest doses of exercise training on the coronary arteries. For this purpose, we will review the association between exercise and coronary atherosclerosis measured using computed tomography, discuss the potential underlying mechanisms for exercise-induced coronary atherosclerosis, determine the clinical relevance of coronary atherosclerosis in middle-aged athletes and describe strategies for the clinical management of athletes with coronary atherosclerosis to guide physicians in clinical decision making and treatment of athletes with elevated coronary artery calcification scores

Epidemiology of Heart Failure

Cardiovascular mortality rates have decline'd significantly in most industrialized countries over the past three decades.2 Nevertheless, cardiovascular disease remains one of the most important causes of morbidity and mortality in Western society, especially as the average age of the population increases.'" Heart failure is rapidly becoming one of the most prevalent cardiovascular disorders and the incidence of heart failure is expected to continue to increase for some time to come.5,6 Unfortunately, it appears that the declining fatality rate of acute coronary events/ resulting in a larger group of persons at increased risk of developing chronic cardiovascular disease, contributes to the rise of heart failure. The paradox of better care is expanded by the observation that treatment of hypertension may actually postpone rather than prevent the onset of heart failure. 8 The prognosis of heart failure is poor9 and the economic impact of heart failure on health services is considerable because of the long-tenn pharmacological treatment and frequent hospitalizations associated with the syndrome. This burden is set to increase further as the prognosis of patients with heart failure is improved by medical and surgical interventions10- 13 and the proportion of the elderly increases in Western society

Cardiac imaging to detect coronary artery disease in athletes aged 35 years and older. A scoping review.

Sudden cardiac death (SCD) is a devastating event in athletes. Screening efforts that were first directed at athletes younger than 35 years, are now focusing on the rapidly growing group of older sportspersons. Athletes aged ≥35 years have a 10-fold increased risk of exercise-related cardiac arrest, mostly due to coronary artery disease (CAD). Although cardiac imaging is pivotal in identifying CAD, the role of imaging modalities in screening asymptomatic older sportspersons remains unclear. We performed a scoping review to identify the role of cardiac imaging to detect CAD in older sportspersons and to identify gaps in the existing literature. We searched Medline, Embase and the Cochrane library for studies reporting data on cardiac imaging of CAD in sportspersons ≥35 years. The systematic search yielded 1737 articles and 14 were included in this scoping review. Imaging modalities included 2 echocardiography, 1 unenhanced Computed Tomography (CT) for coronary artery calcium scoring (CACS), 3 CACS and contrast-enhanced CT angiography (CCTA), 2 CACS and Cardiac Magnetic Resonance (CMR), 1 CCTA with CMR and echocardiography, 2 CCTA, 2 CMR, and 1 myocardial perfusion imaging article. The low number of relevant articles and the selection bias introduced by studying specific groups, like veteran marathon runners, indicate the need for future research. Cardiac CT (CACS and CCTA) probably has the highest potential for pre-participation screening, with high diagnostic value to detect CAD and low radiation dose. However, currently there is insufficient evidence for incorporating routine cardiac imaging in the pre-participation screening of asymptomatic sportspersons over 35 years

Historical trends in survival of hospitalized heart failure patients: 2000 versus 1995

BACKGROUND: Population-based secular trends in survival of patients with congestive heart failure (CHF) are central to public health research on the burden of the syndrome. METHODS: Patients 35–79 years old with a CHF discharge code in 1995 or 2000 were identified in 22 Minneapolis-St. Paul hospitals. A sample of the records was abstracted (50% of 1995 records; 38% of 2000 records). A total of 2,257 patients in 1995 and 1,825 patients in 2000 were determined to have had a CHF-related hospitalization. Each patient was followed for one year to ascertain vital status. RESULTS: The risk profile of the 2000 patient cohort was somewhat worse than that of the 1995 cohort in both sex groups, but the distributions of age and left ventricular ejection fraction were similar. Within one year of admission in 2000, 28% of male patients and 27% of female patients have died, compared to 36% and 27% of their counterparts in 1995, respectively. In various Cox regression models the average year effect (2000 vs. 1995) was around 0.75 for men and 0.95 to 1.00 for women. The use of angiotensin converting-enzyme inhibitors and beta-blockers was associated with substantially lower hazard of death during the subsequent year. CONCLUSION: Survival of men who were hospitalized for CHF has improved during the second half of the 1990s. The trend in women was very weak, compatible with little to no change. Documented benefits of angiotensin converting-enzyme inhibitors and beta-blockers were evident in these observational data in both men and women

The Relationship Between Lifelong Exercise Volume and Coronary Atherosclerosis in Athletes.

Background -Higher levels of physical activity are associated with a lower risk of cardiovascular events. Nevertheless, there is debate on the dose-response relationship of exercise and CVD outcomes and whether high volumes of exercise may accelerate coronary atherosclerosis. We aimed to determine the relationship between lifelong exercise volumes and coronary atherosclerosis. Methods -Middle aged men engaged in competitive or recreational leisure sports underwent a non-contrast and contrast-enhanced computed tomography scan to assess coronary artery calcification (CAC) and plaque characteristics. Participants reported lifelong exercise history patterns. Exercise volumes were multiplied by Metabolic Equivalent of Task (MET) scores to calculate MET-min/week. Participants were categorized as 2000 MET-min/week. Results -284 men (55±7 years) were included. CAC was present in 150/284 (53%) participants with a median CAC score of 35.8 [9.3-145.8). Athletes with a lifelong exercise volume >2000 MET-min/week (n=75) had a significantly higher CAC score (9.4 [0-60.9] versus 0 [0-43.5], p=.02) and prevalence of CAC (68%,ORadjusted=3.2 (95%CI: 1.6-6.6)) and plaque (77%, ORadjusted=3.3 (95%CI: 1.6-7.1)) compared to 0, there was no difference in CAC score (p=.20), area (p=.21), density (p=.25) and regions of interest (p=.20) across exercise volume groups. Among participants with plaque, the most active group (>2000 MET-min/week) had a lower prevalence of mixed plaques (48% versus 69%, ORadjusted=0.35 (95%CI: 0.15-0.85) and more often had only calcified plaques (38% versus 16%, ORadjusted=3.57 (95%CI: 1.28-9.97)) compared to the least active group (2000 MET-min/week group had a higher prevalence of CAC and atherosclerotic plaques. The most active group did however have a more benign composition of plaques, with fewer mixed plaques and more often only calcified plaques. These observations may explain the increased longevity typical of endurance athletes despite the presence of more coronary atherosclerotic plaque in the most active participants

Improvement of primary care for patients with chronic heart failure: a pilot study

<p>Abstract</p> <p>Background</p> <p>Many patients with chronic heart failure (CHF) receive treatment in primary care, but data have shown that the quality of care for these patients needs to be improved. We aimed to evaluate the impact and feasibility of a programme for improving primary care for patients with CHF.</p> <p>Methods</p> <p>An observational study was performed in 19 general practices in the south-eastern part of the Netherlands, evaluation involving 15 general practitioners and 77 CHF patients. The programme for improvement comprised educational and organizational components and was delivered by a trained practice visitor to the practices. The evaluation was based on case registration forms completed by health professionals and telephone interviews.</p> <p>Results</p> <p>Management relating to diet and physical exercise seemed to have improved as eight patients were referred to dieticians and five to physiotherapists. The seasonal influenza vaccination rate increased from 94% to 97% (75/77). No impact on smoking was observed. Pharmaceutical treatment was adjusted according to guideline recommendations in 12% of the patients (9/77); 7 patients started recommended medication and 2 patients received dosage adjustments. General practitioners perceived the programme to be feasible. Clinical task delegation to nurses and assistants increased in some practices, but collaboration with other healthcare providers remained limited.</p> <p>Conclusions</p> <p>The improvement programme proved to have moderate impact on patient care. Its effectiveness should be tested in a larger rigorous evaluation study using modifications based on the pilot experiences.</p

Некоторые проблемы добычи полезных ископаемых на глубоких горизонтах недр

Cardiovascular screening may benefit middle-aged sportsmen, as coronary artery disease (CAD) is the main cause of exercise-related sudden cardiac death. Arterial stiffness, as measured by pulse wave velocity (PWV), may help identify sportsmen with subclinical CAD. We examined the additional value of PWV measurements to traditional CAD risk factors for identifying CAD.From the Measuring Athlete's Risk of Cardiovascular events (MARC) cohort of asymptomatic, middle-aged sportsmen who underwent low-dose Cardiac CT (CCT) after routine sports medical examination (SME), 193 consecutive sportsmen (aged 55 ± 6.6 years) were included with additional PWV measurements before CCT. Sensitivity, specificity and predictive values of PWV values (>8.3 and >7.5 m/s) assessed by Arteriograph were used to identify CAD (coronary artery calcium scoring ≥ 100 Agatston Units or coronary CT angiography luminal stenosis ≥ 50%) and to assess the additional diagnostic value of PWV to established cardiovascular risk factors.Forty-seven sportsmen (24%) had CAD on CCT. They were older (58.9 vs. 53.8 years, p<0.001), had more hypertension (17 vs. 4%, p=0.003), higher cholesterol levels (5.7 vs. 5.4 mmol/l) p=0.048), and more often were (ever) smokers (55 vs. 34%, p=0.008). Mean PWV was higher in those with CAD (8.9 vs. 8.0 m/s, p=0.017). For PWV >8.3m/s respectively >7.5 m/s sensitivity to detect CAD on CT was 43% and 74%, specificity 69% and 45%, positive predictive value 31% and 30%, and negative predictive value 79% and 84%. Adding PWV to traditional risk factor models did not change the area under the curve (from 0.78 (95% CI = 0.709-0.848)) to AUC 0.78 (95% CI 0.710-0.848, p = 0.99)) for prediction of CAD on CCT.Limited additional value was found for PWV on top of established risk factors to identify CAD. PWV might still have a role to identify CAD in middle-aged sportsmen if risk factors such as cholesterol are unknown

The prognostic value of automated coronary calcium derived by a deep learning approach on non-ECG gated CT images from ⁸²Rb-PET/CT myocardial perfusion imaging

Background: Assessment of both coronary artery calcium(CAC) scores and myocardial perfusion imaging(MPI) in patients suspected of coronary artery disease(CAD) provides incremental prognostic information. We used an automated method to determine CAC scores on low-dose attenuation correction CT(LDACT) images gathered during MPI in one single assessment. The prognostic value of this automated CAC score is unknown, we therefore investigated the association of this automated CAC scores and major adverse cardiovascular events(MACE) in a large chest-pain cohort. Method: We analyzed 747 symptomatic patients referred for 82RubidiumPET/CT, without a history of coronary revascularization. Ischemia was defined as a summed difference score≥2. We used a validated deep learning(DL) method to determine CAC scores. For survival analysis CAC scores were dichotomized as low(90 days after scanning) or nonfatal myocardial infarction. Cox proportional hazard analysis were performed to identify predictors of MACE. Results: During 4 years follow-up, 115 MACEs were observed. High CAC scores showed higher cumulative event rates, irrespective of ischemia (nonischemic: 25.8% vs 11.9% and ischemic: 57.6% vs 23.4%, P-values <0.001). Multivariable cox regression revealed both high CAC scores (HR 2.19 95%CI 1.43–3.35) and ischemia (HR 2.56 95%CI 1.71–3.35) as independent predictors of MACE. Addition of automated CAC scores showed a net reclassification improvement of 0.13(0.022–0.245). Conclusion: Automatically derived CAC scores determined during a single imaging session are independently associated with MACE. This validated DL method could improve risk stratification and subsequently lead to more personalized treatment in patients suspected of CAD