FATTORI DI RISCHIO CARDIOVASCOLARI IN PARENTI DI PRIMO GRADO DI SOGGETTI CON MALATTIA CORONARICA PREMATURA
I dati dello studio GENECERD su gruppi familiari indicano la presenza di una predisposizione familiare, in parte genetica, per l'obesità addominale, l'ipertensione e l'ipercolesterolemia in famiglie con patologia coronarica prematura.

[HIGH PREVALENCE OF MAJOR CARDIOVASCULAR RISK FACTORS IN FIRST-DEGREE RELATIVES OF INDIVIDUALS WITH FAMILIAL PREMATURE CORONARY ARTERY DISEASE - THE GENECARD PROJECT. Atherosclerosis 2007; 194:253-264]

ABSTRACT
BACKGROUND Hypertension, hypercholesterolemia, obesity and smoking are highly prevalent among patients with familial premature coronary artery disease (FP-CAD). Whether these risk factors equally affect other family members remains unknown.
METHODS We examined 222 FP-CAD patients, 158 unaffected sibs, 197 offspring and 94 spouses in 108 FP-CAD families (?2 sibs having survived CAD diagnosed before age 51 (M)/56 (F)), and compared them to population controls.
RESULTS Unaffected sibs had a higher prevalence of hypertension (49% versus 24%, p < 0.001), hypercholesterolemia (47% versus 34%, p = 0.002), abdominal obesity (35% versus 24%, p = 0.006) and smoking (39% versus 24%, p = 0.001) than population controls. Offspring had a higher prevalence of hypertension (females), hypercholesterolemia and abdominal obesity than population controls. No difference was observed between spouses and controls. Compared to unaffected sibs, FP-CAD affected sibs had a similar risk factor profile, except for smoking, which was more prevalent (76% versus 39%, p = 0.008).
CONCLUSIONS Hypertension, obesity and hypercholesterolemia are highly prevalent among first-degree relatives, but not spouses, of patients with FP-CAD. These persons deserve special medical attention due to their familial/genetic susceptibility to atherogenic metabolic abnormalities. In these families, smoking may be the trigger for FP-CAD.

SOVRAPPESO E PATOLOGIA CORONARICA
Un nuovo studio ha mostrato che essere moderatamente in sovrappeso aumenta il rischio di malattia coronarica indipendentemente dagli effetti dell'eccesso di peso sulla pressione arteriosa e sul colesterolo; i risultati suggeriscono la necessità di incorporare un indice di sovrappeso o di obesità nei modelli di stratificazione del rischio.

[ASSOCIATION OF OVERWEIGHT WITH INCREASED RISK OF CORONARY HEART DISEASE PARTLY INDEPENDENT OF BLOOD PRESSURE AND CHOLESTEROL LEVELS. A META-ANALYSIS OF 21 COHORT STUDIES INCLUDING MORE THAN 300 000 PERSONS. Arch Intern Med 2007; 167:1720-1728]

ABSTRACT
BACKGROUND The extent to which moderate overweight (body mass index [BMI], 25.0-29.9 [calculated as weight in kilograms divided by height in meters squared]) and obesity (BMI, 30.0) are associated with increased risk of coronary heart disease (CHD) through adverse effects on blood pressure and cholesterol levels is unclear, as is the risk of CHD that remains after these mediating effects are considered.
METHODS Relative risks (RRs) of CHD associated with moderate overweight and obesity with and without adjustment for blood pressure and cholesterol concentrations were calculated by the members of a collaboration of prospective cohort studies of healthy, mainly white persons and pooled by means of random-effects models (RRs for categories of BMI in 14 cohorts and for continuous BMI in 21 cohorts; total N = 302 296).
RESULTS A total of 18 000 CHD events occurred during follow-up. The age-, sex-, physical activity-, and smoking-adjusted RRs (95% confidence intervals) for moderate overweight and obesity compared with normal weight were 1.32 (1.24-1.40) and 1.81 (1.56-2.10), respectively. Additional adjustment for blood pressure and cholesterol levels reduced the RR to 1.17 (1.11-1.23) for moderate overweight and to 1.49 (1.32-1.67) for obesity. The RR associated with a 5-unit BMI increment was 1.29 (1.22-1.35) before and 1.16 (1.11-1.21) after adjustment for blood pressure and cholesterol levels.
CONCLUSIONS Adverse effects of overweight on blood pressure and cholesterol levels could account for about 45% of the increased risk of CHD. Even for moderate overweight, there is a significant increased risk of CHD independent of these traditional risk factors, although confounding (eg, by dietary factors) cannot be completely ruled out.

PRESSIONE ARTERIOSA E IMC E RISCHIO DI INSUFFICIENZA CARDIACA
Un nuovo studio suggerisce che l'elevata pressione arteriosa ed un alto indice di massa corporea (IMC) in soggetti adulti aumentano il rischio di insufficienza cardiaca in età più avanzata.

[ANTECEDENT BLOOD PRESSURE, BODY MASS INDEX, AND THE RISK OF INCIDENT HEART FAILURE IN LATER LIFE. Hypertension, pubblicato on line il 24 settembre 2007]

ABSTRACT
Higher blood pressure and body mass index (BMI) are risk factors for heart failure. It is unknown whether the presence of these risk factors in midadulthood affect the future development of heart failure. In the community-based Framingham Heart Study, we examined the associations of antecedent blood pressure and BMI with heart failure incidence in later life. We studied 3362 participants (57% women; mean age: 62 years) who attended routine examinations between 1969 and 1994 and examined their systolic and diastolic blood pressure, pulse pressure, and BMI at current (baseline), recent (average of readings obtained 1 to 10 years before baseline), and remote (average of readings obtained 11 to 20 years before baseline) time periods. During 67 240 person-years of follow-up, 518 participants (280 women) developed heart failure. Current, recent, and remote systolic pressure; pulse pressure; and BMI were individually associated with incident heart failure (all P<0.001). Recent systolic pressure (hazards ratio [HR] per 1-SD increment: 1.31; 95% CI: 1.11 to 1.55), pulse pressure (HR per 1-SD increment: 1.33; 95% CI: 1.14 to 1.54), and BMI (HR per unit increase: 1.15; 95% CI: 1.08 to 1.23) were associated with heart failure risk even after adjusting for current measures. Similarly, remote systolic pressure (HR per 1 SD: 1.17; 95% CI: 1.04 to 1.31), pulse pressure (HR per 1 SD: 1.17; 95% CI: 1.06 to 1.31), and BMI (HR per unit: 1.09; 95% CI: 1.05 to 1.14) remained associated with incident heart failure after adjusting for current measurements. Higher blood pressure and BMI in midlife are harbingers of increased risk of heart failure in later life. Early risk factor modification may decrease heart failure burden.

Associations of antecedent blood pressure with incident heart failure

Results are age-stratified and adjusted for age, sex, serum cholesterol, hypertension treatment, diabetes, smoking, valve disease, previous MI (all defined at the baseline examination) and for the incidence of an interim MI on follow-up. Models evaluating systolic BP variables are adjusted for baseline diastolic BP. Models evaluating diastolic BP variables are adjusted for baseline systolic BP.

Associations of antecedent BMI with incident heart failure

Results are age-stratified and adjusted for age, sex, serum cholesterol, systolic and diastolic BP, hypertension treatment, diabetes, smoking, valve disease, previous MI (all defined at the baseline examination), and for incidence of an interim MI on follow-up

ACCURATEZZA PROGNOSTICA DELLA MISURAZIONE DELLA PRESSIONE EFFETTUATA DI GIORNO O DI NOTTE
La pressione arteriosa misurata durante il giorno, aggiustata in funzioni dei valori notturni, è predittiva di eventi cardiovascolari fatali e non, tranne nei pazienti in trattamento farmacologico; questi risultati rilevano la necessità di effettuare misurazioni durante l'intera giornata.

[PROGNOSTIC ACCURACY OF DAY VERSUS NIGHT AMBULATORY BLOOD PRESSURE: A COHORT STUDY. Lancet 2007; 370:1219-29]

SUMMARY
BACKGROUND Few studies have formally compared the predictive value of the blood pressure at night over and beyond the daytime value. We investigated the prognostic significance of the ambulatory blood pressure during night and day and of the night-to-day blood pressure ratio.
METHODS We did 24-h blood pressure monitoring in 7458 people (mean age 56·8 years [SD 13·9]) enrolled in prospective population studies in Denmark, Belgium, Japan, Sweden, Uruguay, and China. We calculated multivariate-adjusted hazard ratios for daytime and night-time blood pressure and the systolic night-to-day ratio, while adjusting for cohort and cardiovascular risk factors.
FINDINGS Median follow-up was 9·6 years (5th to 95th percentile 2·5-13·7). Adjusted for daytime blood pressure, night-time blood pressure predicted total (n=983; p<0·0001), cardiovascular (n=387; p<0·01), and non-cardiovascular (n=560; p<0·001) mortality. Conversely, adjusted for night-time blood pressure, daytime blood pressure predicted only non-cardiovascular mortality (p<0·05), with lower blood pressure levels being associated with increased risk. Both daytime and night-time blood pressure consistently predicted all cardiovascular events (n=943; p<0·05) and stroke (n=420; p<0·01). Adjusted for night-time blood pressure, daytime blood pressure lost prognostic significance only for cardiac events (n=525; p?0·07). Adjusted for the 24-h blood pressure, night-to-day ratio predicted mortality, but not fatal combined with non-fatal events. Antihypertensive drug treatment removed the significant association between cardiovascular events and the daytime blood pressure. Participants with systolic night-to-day ratio value of 1 or more were older, at higher risk of death, and died at an older age than those whose night-to-day ratio was normal (?0·80 to <0·90).
INTERPRETATION In contrast to commonly held views, daytime blood pressure adjusted for night-time blood pressure predicts fatal combined with non-fatal cardiovascular events, except in treated patients, in whom antihypertensive drugs might reduce blood pressure during the day, but not at night. The increased mortality in patients with higher night-time than daytime blood pressure probably indicates reverse causality. Our findings support recording the ambulatory blood pressure during the whole day.

SCARSO CONTROLLO GLICEMICO ED EVENTI CARDIOVASCOLARI
Un'analisi retrospettiva effettuata su un ampio managed-care database suggerisce che soggetti diabetici con livelli di emoglobina glicata oltre il 7% mostrano un rischio maggiore di eventi cardiovascolari.

[CV EVENTS LINKED TO POOR GLYCEMIC CONTROL . The Heart.org, pubblicato on line il 20 settembre 2007]

Amsterdam, the Netherlands - Poor glycemic control in diabetics is linked to an increased risk of cardiovascular events, a large retrospective study suggests. Examining data from almost 70 000 diabetics enrolled in the Integrated Health Care Information System database (IHCIS), researchers from Yale report that rates of first acute MI and CABG, but not stroke, over more than two years of follow-up were higher for subjects with higher HbA1C levels at baseline.
Dr Joseph Thomas (Yale University, New Haven, CT) reported the results of the analysis here at the European Association for the Study of Diabetes 2007 Meeting. While poor glycemic control has well-established ties to microvascular and macrovascular disease, the link with hard cardiovascular events is less clear, with much of the current debate on the cardiovascular safety of diabetes drugs-thiazolidinediones in particular-circling around the fact they were approved on the grounds that they successfully improved glucose control and not because of their effects on cardiovascular outcomes.
Now, with the caveat that the study was retrospective and included relatively healthy, younger individuals, Thomas said that it nevertheless provides insights into the importance of controlling glucose.
"An elevated index A1C is a significant risk factor for AMI and CABG, with poorer survival," he said. "Glycemic control is associated with real-world, long-term macrovascular outcomes, and early intervention with intensive diabetes treatment may reduce macrovascular events."
Thomas and colleagues stratified patients across quartiles of index HbA1C level, using the cut points of <6%, 6% to 7%, 7% to 9%, and >9%. Over a mean of more than two years of follow-up, unadjusted incidence rates were highest in the 7%-9% HbA1C group, seeming to level off above 7%. Of note, subjects in the highest HbA1C group also had the most other risk factors for CVD and were more likely to be taking cardiovascular medications and insulin.
Rates of AMI, CABG, and stroke per 1000 person-years

After adjustment for comorbidities and diabetes, lipid-lowering, and antihypertensive drugs, the link between high HbA1C levels and cardiovascular risk was even stronger. Compared with the <6% group, the hazard risk for the combined end point of AMI, CABG, and stroke was 8% higher in the 7%-9% HbA1C group and 15% higher in the >9% HbA1C group.
Kaplan-Meier survival curves looking at time to death/AMI pointed to significantly worse survival for subjects in the 7%-9% HbA1C group, with a hazard ratio of 1.33, and for subjects in the highest HbA1C category, with a hazard ratio of 1.57, as compared with subjects in the lowest HbA1C group. Similarly, for the end point of death/CABG, hazard ratios were also increased in these groups, at 1.38 and 1.56, respectively.
No differences between HbA1C groups were seen for the stroke end point, a finding that Thomas acknowledged was not in keeping with the other findings. During the discussion, however, moderator Dr Diethelm Tschöpe (Ruhr-Universitat Bochum, Bad Oeynhausen, Germany) pointed out that "the truth may be very different," since researchers may not have been able to glean accurate information on stroke from the IHCIS database.
Thomas agreed, adding that the analysis had not been able to take into account transient ischemic attacks (TIAs). "We were not at times clear as to whether TIAs should be considered as strokes, but additional analyses, if we had included TIAs, would perhaps have changed the data."
A number of ongoing trials are addressing the question of whether lowering HbA1C levels with insulin therapy can improve CV outcomes, among them the ORIGIN, ACCORD, and the VADT trials, Thomas noted.

EMOGLOBINA GLICATA ED EVENTI CV NON FATALI
I ricercatori hanno rilevato un'associazione tra HbA1c e CVD non fatali, che permane dopo aggiustamento per gli altri fattori di rischio cardiovascolari, anche in pazienti non diabetici.

[ELEVATED HBA1C ASSOCIATED WITH NONFATAL CVD, EVEN IN NONDIABETICS. The Heart.org, pubblicato on line il 18 settembre 2007]

Amsterdam, the Netherlands - Even in nondiabetics, increased HbA1c levels are associated with a significantly increased risk of nonfatal cardiovascular disease after other cardiovascular risk factors are accounted for, an analysis from the Hoorn cohort study shows.
While HbA1c is a well-established predictor of cardiovascular events in diabetics, this is the first study to link elevated HbA1c to fatal and nonfatal cardiovascular disease in nondiabetics, Dr Esther van 't Riet (VU University Medical Centre, Amsterdam, the Netherlands) reported here at the European Association for the Study of Diabetes 2007 Meeting.
"The clinical meaning of this is that, even in subjects without diabetes, it is very important to maintain optimal glycemic control," van 't Riet told heartwire. "Trying to lower HbA1c may not be the first thing you do in terms of treatment, but you can see that when you have subjects without diabetes who have high HbA1c levels there is some degree of risk, and when you lower HBA1c you lower their risk of CVD. This is evidence of that relationship."
The Hoorn study is a population-based cohort analysis that enrolled 2484 subjects back in 1989 to 1990. A total of 1674 nondiabetic subjects with data on baseline HbA1c were included in the current analysis and analyzed by tertiles of baseline HbA1c. As van 't Riet reported here, subjects in the highest HbA1c tertile (>5.6%) had significantly increased risk of developing nonfatal cardiovascular disease or dying of cardiovascular disease, even after adjustment for age and sex: hazard ratios of 2.11 and 1.73, respectively. When the analysis was further adjusted for cardiovascular risk factors (hypertension, smoking, LDL, triglycerides, and waist-to-hip ratio), a high HbA1c was still significantly associated with nonfatal CVD (but not fatal CVD), with a hazard ratio of 1.71.
Fasting glucose levels at baseline and measures of two-hour plasma glucose were not significantly associated with increased CVD risk.
No link to impaired glucose tolerance
To heartwire, van 't Riet said that the lack of an association with fasting glucose levels comes as no surprise: no previous reports have linked fasting glucose to CVD in nondiabetics. More surprising, however, was the lack of association with two-hour plasma glucose levels-a measure of impaired glucose tolerance. "That has been reported before, in several large epidemiological studies," she said, "But I think difference comes from the fact that we excluded all diabetic subjects, whereas earlier reports included diabetic subjects. We did an analysis in which we included diabetic subjects [from the Hoorn cohort] and when we did that, we did find an association with two-hour glucose levels."
Commenting on the study, Dr John S Yudkin (University College London, UK) also observed that he would have expected impaired glucose tolerance to be "a better marker" than HbA1c. He also speculated on the significance of HbA1c as a measurement.
Obviously one big question is whether HbA1c is a mediator of cardiovascular risk or merely a marker. Some of the excess risk seems to disappear when the measured CV risk factors are adjusted for, and those measured markers would also probably couple with other unmeasured ones like microalbuminuria, fibrinogen, and CRP, he proposed.
To heartwire, van 't Riet said that, in her opinion, HbA1c is probably a marker, whereas glucose is more of a mediator. But she reiterated that she didn't think HbA1c would necessarily be a good marker to aggressively target in clinical practice. "When you go to treat an individual to lower their HbA1c to decrease their risk of CVD, you are targeting a hazard ratio of 1.71, but when you treat blood pressure or cholesterol, you have the potential to have a much bigger effect on CVD outcomes. I think it's much better to treat blood pressure and cholesterol than HbA1c in subjects without diabetes."

CONSUMO DI VINO E LIVELLI GLICEMICI NEI DIABETICI
Un bicchiere di vino a pasto può migliorare il controllo glicemico nei diabetici di tipo 2, soprattutto in caso di elevati livelli di HbA1c.

[MODERATE WINE CONSUMPTION IMPROVES FASTING PLASMA GLUCOSE LEVELS IN DIABETICS. The Heart.org, pubblicato on line il 21 settembre 2007]

Amsterdam, the Netherlands - A randomized trial conducted in diabetic teetotalers suggests that a glass of wine with dinner may improve glucose control, particularly in those with higher HbA1c levels to begin with. The study, while small, adds to anecdotal evidence and meta-analyses that suggest wine, whose cardiovascular benefits have been widely touted, may hold specific benefits for diabetics.
Dr Iris Shai (Ben Gurion University, Beer-Sheva, Israel) presented the results of the study here at the European Association for the Study of Diabetes 2007 Meeting.
Shai noted that the proportion of alcohol abstainers is relatively high in Israel, where the study was conducted; however, the potential health benefits of moderate alcohol consumption persuaded 109 adults between the ages of 40 and 75 to participate. Indeed, dropouts during the three-month trial were higher among those randomized to the nonalcoholic diet malt beer than among those randomized to their choice of red or white wine, with many of the dropouts citing their disappointment over not being assigned to the alcohol group.
At the end of three months, 91 subjects remained in the study; those in the alcohol-intervention group experienced a statistically significant drop in fasting plasma glucose, from a mean of 139.6 mg/dL to 118 mg/dL. By contrast, subjects in the nonalcoholic-beer group experienced no real change in fasting plasma glucose.
Of note, alcohol consumption did not appear to affect two-hour postprandial glucose levels. Shai pointed out that ethanol metabolism is believed to inhibit gluconeogenesis, which could increase the risk of hypoglycemia. "Because of this, patients were guided to drink their beverage during dinner, which was a carbohydrate-based meal. But this process largely controls fasting, rather than postmeal, glycemia," she said, which might help explain the lack of an effect on two-hour postprandial glucose.
Better glucose, better sleep
Changes in fasting plasma glucose levels were particularly marked among patients who had higher baseline HbA1c levels, Shai noted. Waist circumference and LDL levels were also reduced from baseline over the three-month period in the alcohol-intervention group, but no changes from baseline were seen in HDL levels. While "surprising," Shai suggested that the lack of effect on HDL might be due to the relatively short duration of the trial.
Prompting giggles in the audience, Shai said that despite a range of other parameters queried or measured in the trial, the only other significant difference between the two study groups was an improved ability to fall asleep, reported in the alcohol-intervention arm of the study.
Three months after the termination of the trial, 61% of the study subjects told investigators that they believed alcohol was likely beneficial and 49% were continuing to drink alcohol in moderation.

DIABETE E INTOLLERANZA AL GLUCOSIO IN SEGUITO AD INFARTO MIOCARDICO ACUTO ED EFFETTO DEI FATTORI DI RISCHIO
Se è ben chiaro che il diabete è pericoloso per il cuore, molto meno si è indagato sulla relazione inversa, cioè sul rischio di sviluppare la malattia metabolica in seguito a un recente attacco cardiaco.

[INCIDENCE OF NEW-ONSET DIABETES AND IMPAIRED FASTING GLUCOSE IN PATIENTS WITH RECENT MYOCARDIAL INFARCTION AND THE EFFECT OF CLINICAL AND LIFESTYLE RISK FACTORS. Lancet 2007; 370:667-75]

ABSTRACT
BACKGROUND Individuals with diabetes are at higher risk of myocardial infarction than non-diabetics. However, much less is known about the incidence of, and risk factors for, development of diabetes and impaired fasting glucose in patients who have had a myocardial infarction. We set out to estimate this incidence and investigate whether lifestyle factors such as dietary habits might alter this risk.
METHODS We used prospectively obtained data for 8291 Italian patients with a myocardial infarction within the previous 3 months, who were free of diabetes (determined by medication use, a physician-reported diagnosis, or fasting glucose > or =7 mmol/L) at baseline. Incidence of new-onset diabetes (new diabetes medication or fasting glucose > or =7 mmol/L) and impaired fasting glucose (fasting glucose > or =6.1 mmol/L and <7 mmol/L) were assessed at follow-up at 0.5, 1.0, 1.5, 2.5, and 3.5 years. Baseline data for body-mass index (BMI), other risk factors, dietary habits, and medications were updated during follow-up. A Mediterranean diet score was assigned according to consumption of cooked and raw vegetables, fruit, fish, and olive oil. Associations of demographic, clinical, and lifestyle risk-factors with incidence of diabetes and impaired fasting glucose were assessed with multivariable Cox proportional hazards.
FINDINGS During 26 795 person-years (mean follow-up 3.2 years [SD 0.9]), 998 individuals (12%) developed new-onset diabetes (incidence 37 cases per 1000 person-years). Of the 7533 without impaired fasting glucose at baseline, 2514 (33%) developed new-onset impaired fasting glucose or diabetes (incidence 123 cases per 1000 person-years), rising to 3859 (62%) of 6229 with the lower cutoff for impaired fasting glucose of 5.6 mmol/L (incidence 321 cases per 1000 person-years). Independent risk factors for new-onset diabetes or impaired fasting glucose included older age, hypertension, use of beta-blockers, lipid-lowering medications (protective), and diuretic use. Independent lifestyle risk-factors included higher BMI, greater BMI gain during follow-up, current smoking, a lower Mediterranean dietary score, and wine consumption of more than 1 L/day. Data for physical activity were unavailable, but inability to perform exercise testing was associated with higher incidence of diabetes and impaired fasting glucose.
INTERPRETATION Compared with population-based cohorts, patients with a recent myocardial infarction had a higher annual incidence rate of impaired fasting glucose (1.8 vs 27.5% in our study) and diabetes (0.8-1.6% compared with 3.7%) in this study. Thus, our results indicate that myocardial infarction could be a prediabetes risk equivalent. Smoking cessation, prevention of weight gain, and consumption of typical Mediterranean foods might lower this risk, which emphasises the need for guidance on diet and other lifestyle factors for patients who have had a myocardial infarction.

CONCENTRAZIONI PLASMATICHE DI ADIPONETTINA DOPO INFARTO MIOCARDICO ACUTO E FUTURI EVENTI CARDIACI
Lo scopo dello studio era di indagare le variazioni dei livelli plasmatici di adiponettina dopo IMA in uomini e donne, al fine di delineare eventuali differenze fra i due sessi in relazione all'incidenza di eventi cardiaci e di definire il ruolo delle concentrazioni di adiponettina in tali differenze.

[FUTURE ADVERSE CARDIAC EVENTS CAN BE PREDICTED BY PERSISTENTLY LOW PLASMA ADIPONECTIN CONCENTRATIONS IN MEN AND MARKED REDUCTIONS OF ADIPONECTIN IN WOMEN AFTER ACUTE MYOCARDIAL INFARCTION. Atherosclerosis 2007; 194:204-213]

ABSTRACT
There is conflicting information about whether mortality after AMI is higher in women than men. We investigated the significance of plasma adiponectin concentrations on major adverse cardiac events (MACE) after acute myocardial infarction (AMI) to delineate any differences between men and women. The study patients consisted of 114 men and 42 women with AMI. The incidence of MACE was significantly higher in women than men during the entire follow-up period (p < 0.05). Compared with men for post-AMI MACE, the hazard ratio for women was 5.6 after adjustment for prognostic factors. Killip class (p < 0.001) and sex differences (p < 0.05) were independent predictors of MACE at 1 year post-AMI. Plasma adiponectin levels in women were significantly higher than men on admission (8.66 _g/mL [range: 6.6-14.08] versus 4.71 microg/mL [range: 3.47-7.27], p < 0.0001) and during the post-AMI course (all p < 0.0001). Multivariate analysis identified plasma adiponectin level on admission as an independent predictor of MACE in men (p < 0.001) and the difference between plasma adiponectin levels at discharge and on admission in women (p < 0.05). Patterns of serial changes in plasma adiponectin concentrations are different between men and women and plasma adiponectin concentrations can be used to predict future adverse cardiac events in AMI patients.

EFFICIENZA CARDIORESPIRATORIA ASSOCIATA ALLA VALUTAZIONE DEL RISCHIO CORONARICO E DI MORTE CARDIOVASCOLARE E PER TUTTE LE CAUSE
Lo scopo dello studio era di determinare se il massimo uptake di ossigeno (VO2peak), una misura accurata e riproducibile di efficienza cardiorespiratoria, insieme alla valutazione del rischio cardiovascolare globale, possa fornire utili informazioni per la stratificazione del rischio in relazione alla morbilità e alla mortalità cardiovascolare e per tutte le cause.

[THE PREDICTIVE VALUE OF CARDIORESPIRATORY FITNESS COMBINED WITH CORONARY RISK EVALUATION AND THE RISK OF CARDIOVASCULAR AND ALL-CAUSE DEATH. J Intern Med. 2007; 262(2):263-72]

ABSTRACT
BACKGROUND There are no data on directly measured cardiorespiratory fitness combined coronary risk evaluation with respect to death from cardiovascular diseases and all-causes. We investigated the prognostic significance of risk scores and cardiorespiratory fitness with respect to cardiovascular disease and all-cause mortality.
METHODS Cardiorespiratory fitness (maximal oxygen uptake, VO2peak) was measured by exercise test with an electrically braked cycle ergometer. The study is based on a random population-based sample of 1639 men (42-60 years) without history of type 2 diabetes or atherosclerotic cardiovascular diseases.
RESULTS During an average follow-up of 16 years, a total of 304 deaths occurred. Independent predictors for all-cause death were European Score (for 1% increment, RR 1.15, 95% CI 1.10-1.20), VO2peak (for 1 MET increment, RR 0.84, 95% CI 0.78-0.89), when adjusted for C-reactive protein, alcohol consumption, serum high-density lipoprotein, waist-to-hip ratio, family history of coronary heart disease, exercise-induced ST changes and the use of medications for hypertension, dyslipidaemia or aspirin. Also, Framingham risk score was related to the risk of death (RR 1.05, 95% CI 1.03-1.07, P < 0.001). Subjects with high European or Framingham score and low VO2peak represent the highest risk group.
CONCLUSION An important finding is that the risk scores can be used to identify men for whom low cardiorespiratory fitness predicts an especially high risk for death from cardiovascular and any other cause.

ECCESSO DI MORTALITÀ CARDIOVASCOLARE IN PAZIENTI CON PATOLOGIA DELLE ARTERIE PERIFERICHE
Nonostante i dati e le linee guida evidenziano la necessità di identificare e trattare la malattia delle arterie periferiche, la sua crescente prevalenza porta ad un alto tasso di mortalità, 2 o 3 volte più alto che in soggetti senza la patologia.

[EXCESS CARDIOVASCULAR MORTALITY IN PATIENTS WITH PERIPHERAL ARTERIAL DISEASE IN PRIMARY CARE: 5-YEAR RESULTS OF THE GETABI STUDY. European Society of Cardiology 2007 Congress; September 4, 2007; Vienna, Austria]

ABSTRACT
BACKGROUND PAD denotes stenotic, occlusive, and aneurysmal diseases of the aorta and its branch arteries, exclusive of the coronary arteries.(1) PAD effects an estimated 8 million people in the United States alone and, as a marker for systemic atherosclerotic disease, increases the risk of cardiovascular mortality four to five times over that of an individual without PAD.(2) Only a fraction of affected patients present with intermittent claudication, considered a classic manifestation of PAD, demonstrating that in most patients, PAD is predominantly asymptomatic.(3) To diagnose PAD, guidelines recommend simply measuring the ABI, which is a fast yet effective method of documenting circulatory function in the lower limb. A normal ABI, >1.0, indicates good blood flow; however, ABI <0.9 is cause for concern and suggests the presence of PAD, while an ABI <0.5 indicates severe blood flow. Compared to angiography, an ABI <0.9 is 90% sensitive and 98% specific for a stenosis of 50% or more in leg arteries.(4,5)
STUDY DESIGN To provide more representative data on PAD and its effects, researchers in Germany undertook the German Epidemiological Trial on Ankle Brachial Index (getABI), enrolling 6,880 unselected patients age 65 years or older in 344 representative German practices.(6) Visits include those done at baseline, 6, 12, 36, and 60 months with the study ongoing. The getABI study was designed to estimate disease prevalence, determine risk factor profiles, and assess relative risk of mortality.
getABI STUDY: 5-YEAR RESULTS At 5 years, overall prevalence was 18.0%, increasing to 35.5% when distal calf stenosis and occlusions were included. At 3 years, all-cause mortality was twice as high in asymptomatic PAD patients compared to those with no PAD (4.1% vs. 9%) and three times as high in symptomatic patients (12.8%). At 5 years the all-cause mortality rates were 9.4%, 19.1%, and 23.9% respectively. ABI was an important marker of mortality risk: those with the lower readings (ABI <0.7) had far worse chances of survival than patients with more moderate PAD. Additionally, during some time points, patients with asymptomatic PAD actually had lower all-cause survival rates than those with symptomatic PAD, likely indicating under-treatment of the disease in the asymptomatic cohort. Overall, getABI demonstrated that patients with PAD alone receive far less treatment than patients with coronary heart disease or cardiovascular disease, based on a history of stroke, MI, or coronary revascularization. According to Curt Diehm, MD, PhD, who presented the 5-year getABI results at ESC 07, PAD patients tend to be "treated like a second class thrombosis patient. That means they are under-treated in terms of statin therapy or platelet-inhibiting drugs or beta-blockers for instance." And, he said, few people appreciate the high risk of mortality in these patients. The news, he said, is that PAD has moved from a disease of the legs that is important for local vascular events, such as amputation, to a realization that PAD is a "systemic disease showing a very high risk of mortality. We know today that if you have (PAD) you die 10 years earlier; 70% of these patients get myocardial infarctions, and about 5-11% get stroke". He stressed that cardiologists need to recognize that these are high-risk patients, regularly perform ABI to find those patients with PAD, and then initiate appropriate secondary prevention, which "should be absolutely the same as coronary heart disease - but look to treat these (PAD) patients in a much more aggressive manner to reduce this high mortality rate."

STRESS LAVORATIVO E RISCHIO DI EVENTI CORONARICI ACUTI RICORRENTI
In un gruppo di uomini e donne di mezza età, tornati a lavorare dopo un infarto miocardico acuto, lo stress sul lavoro causava un aumento del rischio di eventi ricorrenti entro 2 anni.

[JOB STRAIN AND RISK OF ACUTE RECURRENT CORONARY HEART DISEASE EVENTS. JAMA. 2007; 298:1652-1660]

ABSTRACT
CONTEXT There is evidence that job strain increases the risk of a first coronary heart disease (CHD) event. However, little is known about its association with the risk of recurrent CHD events after a first myocardial infarction (MI).
OBJECTIVE To determine whether job strain increases the risk of recurrent CHD events.
DESIGN, SETTING, AND PATIENTS Prospective cohort study of 972 men and women aged 35 to 59 years who returned to work after a first MI and were then followed up between February 10, 1996, and June 22, 2005. Patients were interviewed at baseline (on average, 6 weeks after their return to work), then after 2 and 6 years subsequently. Job strain, a combination of high psychological demands and low decision latitude, was evaluated in 4 quadrants: high strain (high demands and low latitude), active (high demands and high latitude), passive (low demands and low latitude), and low strain. A chronic job strain variable was constructed based on the first 2 interviews, and patients were divided into those exposed to high strain at both interviews and those unexposed to high strain at 1 or both interviews. The survival analyses were presented separately for 2 periods: before 2.2 years and at 2.2 years and beyond.
MAIN OUTCOME MEASURE The outcome was a composite of fatal CHD, nonfatal MI, and unstable angina.
RESULTS The outcome was documented in 206 patients. In the unadjusted analysis, chronic job strain was associated with recurrent CHD in the second period after 2.2 years of follow-up (hazard ratio [HR], 2.20; 95% CI, 1.32-3.66; respective event rates for patients exposed and unexposed to chronic job strain, 6.18 and 2.81 per 100 person-years). Chronic job strain remained an independent predictor of recurrent CHD in a multivariate model adjusted for 26 potentially confounding factors (HR, 2.00; 95% CI, 1.08-3.72).
CONCLUSION Chronic job strain after a first MI was associated with an increased risk of recurrent CHD.

LEGGE CONTRO IL FUMO E TASSI DI OSPEDALIZZAZIONE PER SINDROME CORONARICA ACUTA
Un nuovo studio mostra che le leggi contro il fumo emanate in molte nazioni possono portare ad una riduzione del tasso di ospedalizzazione per sindrome coronarica acuta.

[IMPACT OF A NATIONAL SMOKING BAN ON THE RATE OF ADMISSIONS TO HOSPITAL WITH ACUTE CORONARY SYNDROMES. European Society of Cardiology 2007 Congress; September 4, 2007; Vienna, Austria]

Vienna, Austria - The implementation of a nationwide smoking ban can result in a significant reduction in the number of hospital admissions for acute coronary syndrome (ACS), a new study has shown. Investigators say the results, which were evident in Ireland just one year after the ban was introduced, provide evidence that a ban on smoking in public spaces can have a significant effect on reducing the burden of ACS.
"It's an observational study, showing that the number of hospitalizations for ACS declined by 11% the year following the smoking ban, and while we can't prove that the smoking ban decreased the admission, this study adds to the evidence that smoking bans are effective in reducing admissions for heart attacks and gives encouragement to people advocating antismoking laws," lead investigator Dr Edward Cronin (Cork University Hospital, Ireland) told heartwire. "It encourages other countries in Europe and the rest of the world to consider implementing smoking bans, because there appear to be definite health benefits."
Presenting the results of the study here at the European Society of Cardiology Scientific Sessions 2007, the investigators said the introduction of a smoking ban in Ireland in 2004 afforded them the opportunity to study the short-term effects the ban would have on admissions for cardiovascular disease. On March 29, 2004, Ireland became the first country in Europe to impose an outright ban on smoking in workplaces. The legislation made it an offence to smoke in workplaces, including pubs and restaurants.
"Within Western Europe, the older European countries, before the admission of the other Eastern countries to the EU, Ireland had the second highest rate of cardiovascular deaths in Europe, after Finland," said Cronin. "With the admission of other countries from the former Eastern Bloc, that's changed a little now, but obviously, cardiovascular disease is a big problem in Ireland."
To determine whether the ban had an effect on admissions for ACS, the investigators obtained data from the Coronary Heart Attack Ireland Register (CHAIR), a registry of all patients admitted to the hospital with ACS in southwestern Ireland. The group analyzed data from six of the eight hospitals included in the region.
From March 29, 2003 to March 29, 2004, a full year before the smoking ban was implemented, there were approximately 1200 patients admitted to the hospital for ACS. After the ban, however, the number of admissions declined 11%, a reduction that occurred mainly in males and appeared to be primarily driven by a reduction in non-ST-segment elevation MI (NSTEMI). The reduction appears to be sustained, say investigators, as the reduction held in 2005-2006. As to why the reduction in ACS was observed mainly via a reduction in NSTEMI, Cronin told heartwire it is unclear, but he suggested that assumptions about what contributes to STEMI and NSTEMI would likely be debated in the future.
Asked if he thought the results were surprising, considering how quickly the benefit of the smoking ban was observed, Cronin said the findings are in line with mechanisms of action.
"There seems to be two reasons why smoking would give somebody a heart attack," he said. "There are the acute effects of smoking that occur within 30 seconds of inhaling that smoke. The platelets get stickier, and the endothelium doesn't function as well. Suddenly, with no smoking anywhere, individuals are removed from that threat, and we'd expect the to see the impact right away. Also, for smokers, they have a higher risk of heart attack, but by giving up smoking, that risk declines very rapidly, and we would expect that to show up within the year."
Cronin said he thinks smoking is declining in Ireland, with data showing reductions in cigarettes sold, but these data need to be confirmed. There was no economic analysis performed as part of the study, but because cardiovascular admissions account for a significant proportion of the health budget, it is reasonable to assume a reduction in healthcare expenditures with the smoking ban, he added.

GAS DI SCARICO ED EFFETTI ISCHEMICI E TROMBOTICI
Il primo studio al mondo ad aver verificato le conseguenze di un'esposizione controllata all'inquinamento ha mostrato un legame tra l'esposizione alle emissioni dei motori Diesel durante l'attività fisica e l'ischemia miocardica in uomini con patologia coronarica stabile.

[ISCHEMIC AND THROMBOTIC EFFECTS OF DILUTE DIESEL-EXHAUST INHALATION IN MEN WITH CORONARY HEART DISEASE. N Engl J Med 2007; 357:1075-1082]

ABSTRACT
BACKGROUND Exposure to air pollution from traffic is associated with adverse cardiovascular events. The mechanisms for this association are unknown. We conducted a controlled exposure to dilute diesel exhaust in patients with stable coronary heart disease to determine the direct effect of air pollution on myocardial, vascular, and fibrinolytic function.
METHODS In a double-blind, randomized, crossover study, 20 men with prior myocardial infarction were exposed, in two separate sessions, to dilute diesel exhaust (300 µg per cubic meter) or filtered air for 1 hour during periods of rest and moderate exercise in a controlled-exposure facility. During the exposure, myocardial ischemia was quantified by ST-segment analysis using continuous 12-lead electrocardiography. Six hours after exposure, vasomotor and fibrinolytic function were assessed by means of intraarterial agonist infusions.
RESULTS During both exposure sessions, the heart rate increased with exercise (P<0.001); the increase was similar during exposure to diesel exhaust and exposure to filtered air (P=0.67). Exercise-induced ST-segment depression was present in all patients, but there was a greater increase in the ischemic burden during exposure to diesel exhaust (-22±4 vs. -8±6 millivolt seconds, P<0.001). Exposure to diesel exhaust did not aggravate preexisting vasomotor dysfunction, but it did reduce the acute release of endothelial tissue plasminogen activator (P=0.009; 35% decrease in the area under the curve).
CONCLUSIONS Brief exposure to dilute diesel exhaust promotes myocardial ischemia and inhibits endogenous fibrinolytic capacity in men with stable coronary heart disease. Our findings point to ischemic and thrombotic mechanisms that may explain in part the observation that exposure to combustion-derived air pollution is associated with adverse cardiovascular events.

PATOLOGIA CORONARICA E CANCRO COLORETTALE
I pazienti con malattia delle arterie coronariche hanno una prevalenza di cancro colorettale almeno doppia rispetto a soggetti senza la patologia in un nuovo studio cinese.

[PREVALENCE OF COLORECTAL NEOPLASM AMONG PATIENTS WITH NEWLY DIAGNOSED CORONARY ARTERY DISEASE. JAMA. 2007; 298:1412-1419]

ABSTRACT
CONTEXT Colorectal neoplasm and coronary artery disease (CAD) share similar risk factors, and their co-occurrence may be associated.
OBJECTIVES To investigate the prevalence of colorectal neoplasm in patients with CAD in a cross-sectional study and to identify the predisposing factors for the association of the 2 diseases.
DESIGN, SETTING, AND PARTICIPANTS Patients in Hong Kong, China, were recruited for screening colonoscopy after undergoing coronary angiography for suspected CAD during November 2004 to June 2006. Presence of CAD (n = 206) was defined as at least 50% diameter stenosis in any 1 of the major coronary arteries; otherwise, patients were considered CAD-negative (n = 208). An age- and sex-matched control group was recruited from the general population (n = 207). Patients were excluded for use of aspirin or statins, personal history of colonic disease, or colonoscopy in the past 10 years.
MAIN OUTCOME MEASURES The prevalence of colorectal neoplasm in CAD-positive, CAD-negative, and general population participants was determined. Bivariate logistic regression was performed to study the association between colorectal neoplasm and CAD and to identify risk factors for the association of the 2 diseases after adjusting for age and sex.
RESULTS The prevalence of colorectal neoplasm in the CAD-positive, CAD-negative, and general population groups was 34.0%, 18.8%, and 20.8% (P < .001 by 2 test), prevalence of advanced lesions was 18.4%, 8.7%, and 5.8% (P < .001), and prevalence of cancer was 4.4%, 0.5%, and 1.4% (P = .02), respectively. Fifty percent of the cancers in CAD-positive participants were early stage. After adjusting for age and sex, an association still existed between colorectal neoplasm and presence of CAD (odds ratio [OR], 1.88; 95% confidence interval [CI], 1.25-2.70; P = .002) and between advanced lesions and presence of CAD (OR, 2.51; 95% CI, 1.43-4.35; P = .001). The metabolic syndrome (OR, 5.99; 95% CI, 1.43-27.94; P = .02) and history of smoking (OR, 4.74; 95% CI, 1.38-18.92; P = .02) were independent factors for the association of advanced colonic lesions and CAD.
CONCLUSIONS In this study population undergoing coronary angiography, the prevalence of colorectal neoplasm was greater in patients with CAD. The association between the presence of advanced colonic lesions and CAD was stronger in persons with the metabolic syndrome and a history of smoking.