[Show abstract][Hide abstract] ABSTRACT: The clinical relevance of slightly increased circulating troponin concentrations in patients with stable coronary heart disease (CHD) several weeks after an acute event or CABG has not been fully evaluated.
Baseline plasma concentrations of troponin T were measured with a high-sensitivity assay (hs-cTnT) (Roche Elecsys) in a cohort of 1050 CHD patients from 30 to 70 years of age. The prognostic value of hs-cTnT on a combined cardiovascular disease (CVD) end point after adjustment for covariates was determined with Cox proportional hazards modeling.
The median hs-cTnT concentration was 10.9 ng/L (interquartile range, 5.1-18.9 ng/L). Increased hs-cTnT concentrations were associated with an older age, history of hypertension and diabetes, more advanced coronary artery disease, and other CHD risk factors. Furthermore, hs-cTnT concentration was strongly correlated with N-terminal pro-B-type natriuretic peptide (NT-proBNP) and cystatin C (ρ = 0.61, and ρ = 0.32, respectively; both P values <0.0001). During a median follow-up of 8.1 years, 150 patients (14.3%) experienced a secondary CVD event. In a multivariate model, hs-cTnT was associated with a hazard ratio (HR) for secondary events of 2.83 (95% CI, 1.68-4.79) when the extreme quartiles were compared. Further adjustment for cystatin C, NT-proBNP, and C-reactive protein attenuated this association only slightly (HR, 2.27; 95% CI, 1.31-3.95); P for trend < 0.002). ROC curve analysis of a clinical model that added hs-cTnT to a baseline model showed nonsignificant improvement in the area under the curve (0.69 vs 0.67), whereas the net reclassification improvement was 17.2% (P = 0.029).
Slightly increased hs-cTnT concentrations in stable CHD patients are associated with several cardiovascular disorders and predict long-term CVD events.
[Show abstract][Hide abstract] ABSTRACT: High serum calcium and phosphate levels have been linked to cardiovascular diseases and all-cause mortality but evidence from longitudinal studies is scarce, especially among patients with pre-existing coronary heart disease. The association between baseline calcium and phosphate and prognosis was examined in a cohort study of patients with stable coronary heart disease.
Serum calcium and phosphate were measured in a cohort of initially 1206 patients undergoing a 3 week rehabilitation programme after an acute cardiovascular event and subsequently being followed-up for 8 years. Multivariate Cox regression was employed to assess the association of quartiles and continuous levels of calcium and phosphate with secondary cardiovascular events and all-cause mortality.
No significant risk elevations were observed for secondary cardiovascular event incidence in models adjusted for a variety of potential confounders. High calcium levels, however, were strongly associated with mortality risk in adjusted models (HR(Q4vsQ1)=2.39 (1.22 to 4.66)). In additional multivariable analyses, the calcium/albumin ratio was predictive for all-cause mortality (HR(Q4vsQ1)=2.66 (1.35 to 5.22)) and marginally predictive for cardiovascular event incidence (HR(Q4vsQ1)=1.74 (1.00 to 3.05)).
Calcium and the ratio of calcium with albumin, its major binding protein, were strongly associated with all-cause mortality among patients with coronary heart disease. The underlying mechanisms and the clinical implications of these findings deserve further study.
No preview · Article · Feb 2012 · Heart (British Cardiac Society)
[Show abstract][Hide abstract] ABSTRACT: Recent longitudinal studies have suggested an association of high serum parathyroid hormone levels (PTH) with elevated cardiovascular risk in the general population. This study presents analyses of the prognostic value of baseline PTH for subsequent cardiovascular events and all-cause mortality in a high-risk population with stable coronary heart disease.
Based on measurements of PTH levels in 1133 patients recruited at two German rehabilitation clinics and followed over 8 years, multivariate Cox regression analysis was performed to estimate the risk of secondary cardiovascular events (including myocardial infarction, stroke and death due to cardiovascular diseases) and all-cause-mortality according to PTH quartiles (Q1-Q4) and continuous PTH concentrations.
During follow-up, 153 cardiovascular events and 124 deaths occurred. Age and sex-adjusted Cox regression analysis yielded statistically significant positive associations of PTH with both cardiovascular event incidence and all-cause mortality (HR (95% CI) per SD increase of PTH: 1.35 (1.21-1.51) and 1.25 (1.11-1.42), respectively). Associations remained essentially unchanged after additional adjustment for multiple cardiovascular risk factors. More detailed dose-response analyses showed strong risk elevation for above-normal levels of PTH (> 95th percentile), with essentially no association at lower levels.
The results of this first detailed study in a cohort of patients with stable coronary heart disease suggest an independent predictive value of above-normal PTH for the prognosis in patients with stable coronary heart disease.
No preview · Article · May 2011 · Heart (British Cardiac Society)
[Show abstract][Hide abstract] ABSTRACT: Serum gamma-glutamyltransferase (gamma-GT) predicts incident cardiovascular disease and mortality. The present study examined whether gamma-GT also is associated with prognosis in patients with stable coronary heart disease.
This study included 1152 participants (aged 30-70 years at baseline) of an in-patient rehabilitation programme after acute coronary syndrome, recruited in two rehabilitation clinics in Germany in the years 1999-2000 (KAROLA study). Until year 8 follow-up, 147 participants had experienced a non-fatal or fatal secondary cardiovascular disease event. Confounder-adjusted Cox proportional hazards models revealed an increase in risk for secondary events over ascending gamma-GT quartiles, with hazard ratios (95% confidence interval) of 1.21 (0.72-2.03), 1.32 (0.80-2.16) and 1.75 (1.08-2.83) for the 2nd, 3rd and 4th in reference to the lowest quartile (Ptrend=0.024). The association with all-cause mortality examined as a secondary outcome was slightly stronger (hazard ratio of 4th quartile: 1.97 [1.15-3.36]; Ptrend=0.017).
In patients with stable coronary heart disease, serum gamma-GT was associated with prognosis independent of a variety of established risk markers. The association appeared similar to that reported for primary cardiovascular disease, which should motivate additional studies of its clinical utility in cardiovascular patient care.
[Show abstract][Hide abstract] ABSTRACT: Recent longitudinal analyses suggested that low levels of serum 25-hydroxyvitamin D (25-OH-D) predict incident cardiovascular disease in initially healthy populations. Because the prognostic value of vitamin D for the occurrence of secondary cardiovascular events remains unclear, we examined the association of baseline 25-OH-D levels with prognosis in patients with stable coronary heart disease (CHD).
Serum 25-OH-D levels from 1,125 CHD patients of 2 German clinics undergoing a 3-week rehabilitation program after an acute cardiovascular event were measured, and participants were followed for up to 8 years. We used multivariate Cox regression analysis to model cardiovascular event incidence (fatal and nonfatal, including myocardial infarction, stroke, and death due to cardiovascular diseases) and all-cause mortality according to 25-OH-D quartiles, categories based on cut points of 15 and 30 ng/mL, or continuous vitamin D concentrations.
During follow-up, 148 cardiovascular events and 121 deaths were recorded. Elevation of risk for the lowest quartile or category in comparison to the highest category was weak and nonsignificant for both incidence (hazard ratio [HR](quartile1) = 1.15 [0.72-1.84], HR(<15 ng/mL) = 1.17 [0.61-2.23]) and mortality (HR(quartile1) = 1.29 [0.77-2.14], HR(<15 ng/mL) = 1.87 [0.91-3.82]) in unadjusted Cox regression analysis and disappeared entirely after adjustment for potential confounders (cardiovascular events: HR(quartile1) = 0.84 [0.47-1.50], HR(<15 ng/mL) = 0.90 [0.41-1.96]; mortality: HR(quartile1) = 0.63 [0.33-1.21], HR(<15 ng/mL) = 0.93 [0.39-2.21]). Models treating vitamin D as a continuous variable likewise suggested no significant associations.
Unlike previous population-based studies, our analysis in high-risk patients with stable CHD does not support a prognostic value of baseline-25-OH-D levels for secondary cardiovascular event incidence or all-cause mortality.
No preview · Article · Jun 2010 · American heart journal
[Show abstract][Hide abstract] ABSTRACT: It has been suggested that the apolipoprotein E (APOE) genotype modifies the effect of dietary and pharmacological interventions for lowering lipid levels. We wanted to determine whether APOE genotyping information would be useful in making lipid-lowering treatment decisions in clinical practice. We included 981 patients with coronary heart disease (CHD) enrolled in an inpatient 3-week standardized rehabilitation program. Of these, 555 (57%) patients received continued statin therapy and 232 (24%) patients received newly initiated statin therapy. Dietary intervention was part of the program only for 194 (20%) patients. Total cholesterol (TC) and low-density lipoprotein cholesterol (LDLC) levels decreased in all the groups of patients during rehabilitation. The decreases were less pronounced among the APOE E2 carriers. However, the observed variation among the groups with respect to reduction of lipid levels was accounted for mainly by the initial lipid levels (30-47%) and only marginally on the APOE genotype (1%) . We therefore found no evidence that APOE genotyping will be useful in guiding dietary or pharmacological lipid-lowering treatment decisions.
[Show abstract][Hide abstract] ABSTRACT: We evaluated the association of symptoms of anxiety and depression with fatal and non-fatal cardiovascular disease events among patients with coronary heart disease and considered several potential underlying pathogenetic links.
This was a prospective cohort study.
In this study, including coronary heart disease patients undergoing an in-patient rehabilitation program, symptoms of anxiety and depression were evaluated with the Hospital Anxiety and Depression Scale (HADS). Fatal and non-fatal cardiovascular disease events were determined during a 3-year follow-up.
Of the 1052 patients with CHD 16.1% showed a borderline and 8.3% a manifest anxiety symptoms score, whereas 11.8 and 5.9% showed a borderline and manifest depressive symptoms score, respectively. During the 3-year follow-up fatal and non-fatal cardiovascular disease events were observed in 73 (6.9%) patients. After adjustment for covariates, patients having manifest anxiety symptoms had a statistically significant hazard ratio (HR) of 2.32 [95% confidence interval (CI) 1.14-4.74] for a cardiovascular disease event, and patients with depressive symptoms had an HR of 1.47 (95% CI 0.62-3.51) compared to other patients. In a model considering anxiety and depressive symptom scores simultaneously, the hazard ratio for a cardiovascular disease event associated with anxiety symptoms increased to 3.31 (95% CI 1.32-8.27), whereas the hazard ratio associated with depressive symptoms decreased (HR 0.62; 95% CI 0.20-1.87). We found a positive association of increased anxiety scores with body mass index and systolic blood pressure.
The study suggests an important role especially for symptoms of anxiety for long-term prognosis of patients with known coronary heart disease. It furthermore suggests that several pathogenetic links may partly explain the increased risk.
No preview · Article · Sep 2007 · European Journal of Cardiovascular Prevention and Rehabilitation
[Show abstract][Hide abstract] ABSTRACT: To evaluate the adherence to nutritional recommendations in inpatient rehabilitation and the long term maintenance of dietary changes among patients with coronary heart disease.
Prospective cohort study.
Two rehabilitation clinics in Germany.
A cohort of 1206 patients undergoing inpatient rehabilitation after an acute manifestation of coronary heart disease.
Self reported dietary intake before, during, and one and three years after rehabilitation measured with a semiquantitative food frequency questionnaire and summarised to a nutritional index, which was used to categorise patients as having a poor, fair, or good diet.
During rehabilitation the proportion of patients whose dietary intake was categorised as good increased strongly from 30% to 91%. One and three years after rehabilitation a still increased proportion of 49% and 42%, respectively, in the good category was observed. The strong increase in intake of low fat and wholemeal products that was achieved during rehabilitation was followed after rehabilitation discharge by a backslide to the intake observed before rehabilitation admission. The avoidance of unfavourable food items, such as French fries or eggs, was at least partly maintained during the follow up period.
During inpatient rehabilitation most patients do have to make major changes in their dietary intake to comply with recommendations. Although some proportion of patients continue to adhere to dietary recommendations in the long run, further research into strategies to improve maintenance of dietary changes is needed to enhance further the long term benefits from cardiac rehabilitation.
[Show abstract][Hide abstract] ABSTRACT: To assess the short-term impact of smoking and smoking cessation measured by self-report and by serum cotinine on the risk of secondary cardiovascular disease events (CVD events).
Cohort study among participants of an in-patient 3-week rehabilitation programme following an acute coronary syndrome or coronary artery revascularization. Smoking status at baseline was assessed by self-report (beginning of the rehabilitation programme, rehab) and serum cotinine (end of rehab). Active follow-up was conducted one year later. Subsequent CVD events were observed in 139 of the 967 patients. Both self-reported smoking status (odds ratio (OR) compared to continued smokers: recent quitters 0.96, former smokers 0.83, never smokers 0.54, p for trend 0.04) and serum cotinine (OR 0.59 (95% confidence interval (CI) 0.36-0.97) for cotinine-negative compared to cotinine-positive subjects) were associated with the occurrence of a secondary CVD event. After reclassification of all cotinine-positive subjects to continued smokers and cotinine-negative self-reported smokers to recent quitters, this association became even stronger. The OR now reached 0.71 (95% CI interval 0.38-1.33) for recent quitters, 0.64 (0.36-1.11) for former smokers and 0.44 (0.24-0.81) for never smokers (p-value for trend=0.009).
The benefits of non-smoking and smoking cessation in cardiac patients are beyond controversy and might even be larger than suggested by previous studies which exclusively relied on self-reported smoking status.
Preview · Article · Jan 2005 · European Heart Journal
[Show abstract][Hide abstract] ABSTRACT: Rehabilitation therapy of patients with coronary heart disease (CHD) aims at reducing cardiovascular risk factors and at maintaining reduced risk factor levels. The aim of this analysis was to assess to what degree current in-patient rehabilitation and subsequent out-patient care by general practitioners (GPs) achieve these goals.
As part of the KAROLA-Study (Langzeiterfolge der KARdiOLogischen Anschlussheilbehandlung = Long-term success of cardiological rehabilitation therapy) 1206 patients between 30 and 70 years of age (mean age: male: 58.3 years, female: 60.8 years) who underwent in-patient rehabilitation due to CHD between January 1999 and May 2000 were recruited. Risk factor levels were assessed at the beginning and at the end of in-patient rehabilitation, and patients were re-examined one year after discharge using a standardised exam conducted by the GPs.
Patients with increased risk factor levels at the time of admission showed significant improvements in the following risk factors during rehabilitation: Body mass index (-0.7 kg/m(2)), diastolic blood pressure (-10 mmHg), systolic blood pressure (-10 mmHg), total cholesterol (-73 mg/dl), LDL-cholesterol (-63 mg/dl), HDL-cholesterol (+ 3 mg/dl), triglycerides (-70 mg/dl). One year after discharge, however, all but one of the parameters (LDL-cholesterol) had re-increased significantly. The prescription of lipid lowering drugs rose from 56 % to 76 % during rehabilitation therapy and remained constant during the first year after discharge.
During in-patient rehabilitation therapy important risk factors of CHD improved on average, but these improvements are only partly sustained in the long term. To ensure long-term success of rehabilitation measures more effective maintenance of risk factor modification in subsequent out-patient care is needed.
No preview · Article · Aug 2003 · DMW - Deutsche Medizinische Wochenschrift