Editor's presentation

There is a large body of literature demonstrating the association between depression and anxiety and coronary heart disease.1,2 Contemporary cardiac rehabilitation is focused on optimal outcome and the reduction of possible complications after acute myocardial infarction (AMI) and percutaneous coronary intervention (PCI),3 in which the patient’s mental status is an important factor for recovery. In this issue, significant multivariate predictors of depression and anxiety in patients after PCI are demonstrated.4 Female gender and young age were associated with anxiety, while educated patients and patients with acute coronary events treated by primary PCI had a lower risk of depression. Older age, former smoking and prior myocardial infarction, coronary bypass and stroke were associated with a higher risk of depression. The EUROSPIRE IV study yielded similar results in terms of educational level and age.5 In past decades, a reduction of both hospitalisations and mortality due to AMI has been reported in many developed countries and attributed, at least in part, to risk modification at the population level.6,7 In this issue updated information on trends of incident AMI in Norway are presented: a yearly decline of AMI diagnoses by 2.6% and 2.8% in men and women, respectively, that contributed to the reduction of both AMI hospitalisation and mortality. In 18% of men and 23.3% of women the first AMI was fatal and in 20.1% of cases the death occurred at home, the work place, public places, nursing homes or during transportation.8 The death rates before hospital admission and after hospital discharge have not decreased as wished. More focus towards optimising preventive measures as well as referral to rehabilitation programmes would further help in reducing the mortality burden.9 A systematic review and meta-analysis bringing together data from 19 studies that included over 60,000 women, of which nearly 12,000 had used progestin-only contraceptives, provides robust and reassuring findings that indicate minimal or no effect on cardiometabolic profiles with the use of these agents when given orally.10 However, increased rates of venous thromboembolism and potentially higher rates of diabetes were observed in relation to injectable preparations. Atrial fibrillation is a key cardiovascular risk factor,11 and controversial data have been published concerning its relation with caffeine intake.12 A protective role is supported by a population-based study involving 1475 men and women followed for 12 years, in which coffee or, rather, caffeine intake was associated with decreased risk of atrial fibrillation.13 The multiple health benefits of physical activity14 are confirmed by the Kangbuk Samsung Health Study, a very large cohort study of relatively healthy South Koreans over 18 years old (174,314 subjects) undergoing comprehensive periodic health screenings. After a multivariate adjustment, sufficient baseline physical activity was associated with a lower risk of incident arterial hypertension and showed a lower trend in the incidence of diabetes. Also, even in a relatively short time, increasing physical activity was associated with a lower hypertension and diabetes risk. A digital and decision supportive tool, such as EXPERT, may contribute to enhancing physical activity implementation in clinical practice.15 Maximal oxygen consumption (VO2max) directly measured by open-circuit spirometry during a maximal progressive exercise test is the gold standard measure of peak exercise tolerance,16 but the need for specialised equipment and qualified people limits an extensive application. A new predictive equation to derive VO2max (Fitness Registry and the Importance of Exercise National Database (FRIEND) ergometry equation for cycle ergometer) has been validated, showing a precision similar to the commonly used American College of Sports Medicine (ACSM) equation.17 In Europe, surveys among coronary patients and in high-risk subjects have repeatedly shown that the implementation of the European Society of Cardiology (ESC) guidelines on cardiovascular disease (CVD) prevention in clinical practice is poorly achieved in real life. In keeping with these findings are also the results from the International Cholesterol Management Practice Study (ICLPS), a cross-sectional study from 18 countries (452 centres) in Eastern Europe, Asia, Africa, the Middle East and Latin America.18 It is clear that the implementation of guidelines on CVD prevention into practice necessitates more than combination or more intense lipid-lowering therapies. Based on known barriers, multifaceted interventions are needed.19 Homozygous familial hypercholesterolaemia (HoFH)20 is a rare lipoprotein disorder characterised by extremely elevated low-density lipoprotein (LDL)-cholesterol levels in blood, and therefore an extremely increased risk of premature atherosclerosis with life-threatening CVD. The results of lipoprotein apheresis among six children with HoFH are presented: the youngest patient who started the LDL apheresis treatment was 2 years and 5 months old, being the youngest child treated so far by this method.21 Some hope has recently emerged from the new class of PCSK-9, as a successful treatment for severe hypercholesterolaemia including HoFH.22 The publication of the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines has created a large debate on the medical perspectives, the usefulness, appropriateness, feasibility and scientific nature thereof. The critical point is the implementation of a new definition for hypertension, in which stage 1 hypertension is based on the lower thresholds of 130–139/80–89 mmHg. An economic analysis by the PAST-BP study in England reported that intensive systolic pressure lowering is cost-effective in the presence of a history of stroke, although it was difficult to elucidate whether this benefit was due to the lower target or to more active blood pressure management.23 In this issue, a cost estimation performed for the population of Switzerland showed that the stricter ACC/AHA guidelines would increase by 9% the patients eligible for treatment, translating to an additional 250,000 patients and an annual cost of €63 million. However, the major point remains the feasibility of implementing the targets. The adoption of the new AHA/ACC guidelines in the rest of the world is even more controversial, in weaker health systems of low and middle-income countries, where the burden of hypertension is the greatest. These realities have spurred several new approaches to improve hypertension management, such as the introduction of self-management and the polypill, which have the potential to be cost-effective.24,25 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.