Editorial

Based on the EUROASPIRE IV database,1 it is here reported that only 51% of the patients were advised to participate in a cardiac rehabilitation (CR) programme.2 Older patients, women, those with low educational level, unstable angina, and also those with heart failure (HF), hypertension and disglycaemia less often heard about a CR programme. Among patients advised to undergo CR, as many as 19% missed at least half of the sessions; they tended to have a low educational level and to be smokers prior to the index event. Just 41% of all patients attended at least half of the sessions, with striking geographical variability. A health check should be the first step in a prevention programme in which the next step would be a lifestyle intervention for individuals at high risk.3 Here a review is showing that it is not possible to build a ‘one size fits all’ programme for health checks. The authors identified that key facilitators for participating in a health check were interest in and responsibility for own risk. Major barriers were young age, smoking, being sceptical about prevention, lack of information and difficult access to appointments and, most importantly, low education, indicating possible low socioeconomic status. A web-based health risk assessment for cardiovascular diseases followed by tailored lifestyle advice led to increased physical activity and eating habits.4 An improved control of modifiable risk factors in primary care in patients with multiple risk factors showed a decrease in cardiovascular events.5 The literature forming the evidence for the 1A recommendation for exercise training in HF is reviewed. After very encouraging results from single centre studies and meta-analysis the disappointing results from the large, modern, randomised controlled trials on aerobic exercise training are addressed.6 Also a recent review of current guidelines identified differences in recommendations between key cardiology and CR organisations, further complicating the picture.7 The ‘aerobic/resistance/inspiratory (ARIS) muscle training hypothesis in HF’ is introduced, suggesting that combined ARIS muscle training may result in maximal exercise pathophysiological and functional benefits in these patients. A large database including 787,115 subjects from Western Australia, aged 35–84 years, not surprisingly showed that most cardiovascular events, distinguished as coronary heart disease, cerebrovascular disease and peripheral arterial disease, mostly occurred in older adults. However, a trend towards worsening prevalence in young adults for most cardiovascular subtypes was also observed.8 This is alarming: although the prognosis of survivors of acute coronary syndrome has improved, but even so it is much worse than in the comparable general population.9 In contrast another study from Western Europe found that despite the increase in body weight, the total burden of cardiovascular risk factors had decreased in men aged 50 years in the last half century.10 Income and psychosocial factors play an important role in the prevalence and pathophysiology of cardiovascular diseases.11,12 The significant role of education, monthly income and dwelling location in rheumatic heart disease is here confirmed. The existing disease burden of rheumatic heart disease and its debilitating clinical scenario is more prevalent in low socioeconomic status populations. A meta-analysis including 25 high-quality prospective studies involving 154,794 individuals supported the existence of a positive association between erectile dysfunction and cardiovascular events, with 43%, 59%, 34% and 33% increased risk of cardiovascular disease, coronary artery disease, stroke and all-cause mortality, respectively. Erectile dysfunction predicts deterioration of physical performance in patients after an acute myocardial infarction.13 The diligent observation of at-risk elderly patients and young men should be included routinely to determine the need for pharmacological or life-style interventions addressing cardiovascular risk factors. Shift work usually involves working in the early morning, at night, or at the weekend. Working at night contradicts the terrestrial night outdoors and the biological night of the population. This is because work at night challenges the intrinsic clocks we all have. A rigorous meta-analysis has shown that each 5 years in shift work increases the risk of cardiovascular disease events by 5% and cardiovascular morbidity by 6%. A call has been made loudly to address adverse working conditions, such as shift work.14 This message should be alarming and attract attention from all stakeholders. No association has been observed between total physical activity (PA, including walking, sports, cycling, gardening and hobbies during the past year as collected by replies to the Zutphen questionnaire) and atrial fibrillation (AF) risk in a study involving 7018 participants aged 55 years and older from the Rotterdam Study with information on non-occupational PA between 1997 and 2001. Instead high and very high occupational PA has been associated with a higher risk of AF in 17,196 subjects from the Copenhagen Population Register (hazard ratio 1.21 and 1.39, respectively), whereas there was no significant association with leisure time PA.15 An observational, retrospective analysis of the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial data showed that renin–angiotensin–aldosterone system (RAAS) inhibition significantly reduced the risk of the composite outcome of all-cause mortality, adverse cardiovascular events and HF hospitalisation by 25% in patients with heart failure with preserved ejection fraction (HFpEF) and mild-to-moderate kidney disease (i.e. estimated glomerular filtration rate <60 mL/min/1.73 m2 or urine albumin-to-creatinine ratio ≥30 mg/g).16 Observational data previously demonstrated that long-term neurohormonal blockade with RAAS inhibitors and beta-blockers could protect from the development of new-onset symptomatic HFpEF in high-risk elderly hypertensive patients.17 Moreover, a recent secondary analysis of the TOPCAT data provides new information on the prognostic relevance of neurohormonal overactivity in HFpEF by demonstrating that high resting heart rate is independently associated with adverse outcomes in patients in sinus rhythm, including those receiving beta-blockers.18 The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The author(s) received no financial support for the research, authorship, and/or publication of this article.