Editorial comments: focus on ischaemic heart disease

This special issue is dedicated to several topics related to epidemiology and risk factors in ischaemic heart disease (IHD). Data derived from the Global Burden of Disease and the EuroAspire studies have investigated several aspects providing novel information on how better deal with this clinical condition. The overall message is the major role still played in the year 2022 by IHD, which requires early and accurate diagnosis and effective treatment, including the emphasis on therapeutic optimization and healthy lifestyle promotion. Monitoring the burden of IHD is critically important to reach one of the goals of the United Nations Organization, i.e., to reduce the premature mortality rate from non-communicable diseases by one-third, which could be partially achieved by decreasing cardiovascular diseases (CVDs), and IHD, in particular. Here, three studies based on the systematic analysis of the Global Burden of Disease Study 2019 are presented. The first one aimed to report the global, regional, and national prevalence, deaths, and disability-adjusted life years (DALYs) due to IHD, and its attributable risk factors, for 204 countries and territories from 1990 to 2019, by age, sex, and socio-demographic index. There were decreases in the global age-standardized prevalence rates of IHD, deaths, and DALYs from 1990 to 2019. In 2019, the global prevalence and death rates of IHD were higher among males across all age groups. A negative association was found between the age-standardized DALY rates and socio-demographic index. Globally, high systolic blood pressure (54.6%), high low-density lipoprotein cholesterol (46.6%), and smoking (23.9%) were the three largest contributors to the DALYs attributable to IHD.1 The second one looked at incidence and mortality rates between countries over time: both rates have decreased but varied widely between countries. The relative change was greater for mortality (−60%) than for incidence (−36%). Breakpoint analysis showed that the largest decreases in incidence and mortality occurred between 1990 and 2009, with even a slight increase for some countries in recent years. The decline in both incidence and mortality was lower in the Mediterranean European countries compared to the Nordic and Central European regions.2 Evidence of reduction in incidence and prevalence of IHD is also reported in a New Zealand national registry from 2005 to 2016. These trends were present both in females (3.3% and 3.2%) and in males (2.7% and 2.2%): despite a 17% increase in the population aged 25 years and over during the study period, the total number of people living with IHD decreased, particularly in those aged 65 years and older.3 The third one looked at the changes in quality of care of IHD at the global, and regional levels. Quality of care index (QCI) and gender inequity by the gender disparity ratio (GDR), defined as female to male QCI were computed. From 1990 to 2017, both the QCI and GDR increased; countries of Western Europe, Scandinavia, and Australasia had the highest QCIs and a GDR, while African and South Asian countries had the lowest QCIs and a GDR. Moreover, the young population experienced more significant improvements in the QCI compared to the elderly.4 In conclusion besides some improvements, the remarkable disparities between countries, genders, and age groups should be addressed. These findings may guide policymakers in monitoring and modifying our path. There is evidence from randomized trials that chronic coronary syndrome (CCS) patients do not benefit from revascularization in terms of death or myocardial infarction. Pre-revascularization stress test imaging as well as on-site use of pressure wires could potentially achieve a more personalized and judicious use of revascularization. Vasodilator stress cardiovascular magnetic resonance reliably determines the magnitude of ischaemic burden. Here, a retrospective analysis of 1066 CCS patients, confirmed that revascularization exerts a neutral effect on all-cause mortality in both patients without multi-vessel disease, and with multi-vessel disease without extensive ischaemic burden. However, revascularization significantly reduced all-cause mortality in patients with simultaneous multi-vessel disease and extensive ischaemic burden (>5 segments). Given the limitation due to the observational and retrospective nature of this trial, which is unable to consider all the myriad of factors relevant to the issue, stronger evidence is needed.5 Autoimmune systemic inflammatory diseases (SIDs) are associated with an increased risk of CVD, particularly myocardial infarction (MI). However, there are limited data on the prevalence and effects of SID among adults who experience MI at a young age. The YOUNG-MI registry is a retrospective cohort study which includes patients who experienced the first MI at 50 years of age or younger. Among 2097 individuals, 53 (2.5%) had diagnosis of SID and were more likely women with hypertension. Over a median follow-up of 11.2 years, patients with SID experienced a higher risk of all-cause mortality compared with either the full cohort of non-SID patients or a matched cohort based on age, gender, and CV risk factors. The retrospective nature of this study and the small sample size of young adults with SID did not allow to control for all baseline characteristics and medication.6 In 1968, Weinblatt et al. first reported a paradoxical phenomenon that current smokers had a lower rate of all-cause mortality at 1 month compared with non-smokers (27.5% vs. 38.0%) among 881 MI patients. This finding has been dubbed the ‘smoker’s paradox’. Since then, numerous studies supported this finding, showing that smokers had a significantly lower crude rate of all-cause mortality compared with non-smokers, especially in the era of fibrinolytic therapy. Here, a sub-analysis of the SYNTAX trial investigated the association of smoking status with 10-year all-cause mortality in patients with complex coronary artery disease (CAD) undergoing revascularization and to assess a relative treatment benefit of coronary artery bypass graft vs. percutaneous coronary intervention according to smoking status.7 It was observed that the crude rates of 10-year all-cause mortality was not significantly higher in current smokers (29.7%) than in former smokers (25.3%) and in never smokers (25.9%, P = 0.343). After adjustment for imbalances in baseline characteristics, current smokers had a significantly higher risk of 10-year all-cause mortality than never smokers (adjusted hazard ratio 2.29), whereas former smokers did not. Percutaneous coronary intervention was associated with a higher risk of all-cause mortality than coronary artery bypass graft among current smokers (hazard ratio 1.60), but it failed to show a significant interaction between revascularization strategies and smoking status. Nevertheless, only 60% of patients stopped smoking after revascularization with a relatively high relapse of smoking in the SYNTAX trial, suggesting difficulty in quitting smoking.8 Sexually active patients aged <65 years (n = 495; median age, 53 years), drawn from the longitudinal Israel Study of First Acute Myocardial Infarction, were interviewed during the index hospitalization (1992–93) and after 3–6 months and followed-up for 22 years when 211 (43%) patients died. Maintaining/increasing sexual activity frequency was inversely associated with all-cause mortality, compared with abstaining/reducing. The inverse association was significant for non-cardiovascular mortality. Patients who maintained/increased frequency were more likely to be of higher socioeconomic status and to express lower levels of depression than their abstained/decreased counterparts. In the propensity score-weighted synthetic sample, the distribution of measured baseline covariates was similar across exposure categories, highlighting the need for sexual counselling shortly after MI.9 The large-scale EUROASPIRE surveys have shown a poor control of risk factors in CAD patients with a high risk of recurrent events.10 Here, three analyses of this registry have further investigated this issue, finally providing implications in clinical practice. Previous studies reporting on risk factor management suggest a worse risk factor profile among female patients, despite gender-neutral recommendations. In continuation of previous research and several awareness campaigns, the aim of this study11 was to provide an updated overview on the possibility of gender differences in risk factor control among CAD patients, based on data from the most recent EUROASPIRE V survey, including data across 27 European countries. Data were available for 8261 patients of which 25.8% were women. Overall, women had a worse risk factor control compared with men. Whereas women were more likely to be non-smokers, they were less likely to reach recommended levels of physical activity and to be non-obese, although risk factors such as smoking behaviour and obesity differed depending on country income level. No gender differences could be observed in blood pressure on target although women used anti-hypertensive medication more often. Moreover, a lower proportion of women reached cholesterol target levels, with women being less likely to use lipid-lowering drugs. Finally, less women with diabetes reached the HbA1c target. The conclusion of this study is that the risk factor control of CAD women is substantially worse compared with men despite little gender differences in cardiovascular medication intake. This calls for further actions to increase the awareness of the worse risk factor control in female CAD patients. Most patients with established CVD are at very high risk for developing recurrent events. Since this risk significantly varies among patients, there is a need to identify those in whom an even more intensive secondary prevention strategy should be implemented. Using data from the EUROASPIRE IV and V cohorts of CAD patients from 27 European countries, the aim of this study12 was to develop a new robust risk model for predicting short-term recurrent fatal and non-fatal CVD in patients aged < 75 years. Prospective data were available for 12 484 patients after a median follow-up time of 1.7 years. The final multivariate model revealed a higher risk for the primary endpoint with increasing age, previous hospitalization for stroke, heart failure or coronary revascularization, previous diagnosis of peripheral artery disease, self-reported diabetes, and its glycaemic control, higher non-HDL cholesterol, reduced renal function, symptoms of depression and anxiety, and living in a higher risk country. The model was validated externally in 20 148 MI patients participating in the SWEDEHEART register. Based on these data, the authors developed a risk calculator to estimate risks at 1 and 2 years for patients with stable CAD. These data emphasize that in CAD patients, showing a high risk of fatal and non-fatal recurrent CVD events, there are still opportunities to optimize their management in secondary prevention. The EUROASPIRE Risk Calculator may help reaching this goal. This very poor risk factor control despite a high use of cardioprotective medications indicates a high degree of non-adherence to lifestyle recommendations with the majority of patients failing to achieve the lifestyle goals in terms of smoking and weight-related dietary factors, including sedentary behaviour. The objective of the present study,13 based on data from the EUROASPIRE IV and V surveys, was to investigate specific reasons for poor lifestyle adherence from the perspective of the patient. A total of 16 259 CAD patients were examined and interviewed during a study visit ≥6 months after hospital discharge. Half of those who were smoking prior to hospital admission were still smoking. The prevalence of obesity was 38%. Half of the obese patients tried to lose weight in the past month. In relation to physical activity, 40% was on target with half of the patients trying to do more everyday activities. Only 29% of all patients were at goal for all three lifestyle factors. The number of adverse lifestyles was strongly related to the way patients perceive their illness as threatening. Lifestyle modifications were more successful in those having participated in a cardiac rehabilitation and prevention programme. Patients indicated a lack of self-confidence as the main barrier to change their unhealthy behaviour. In conclusion, most CAD patients still present with unhealthy lifestyle habits at least 6 months following hospital discharge, which emphasizes the need of targeting behavioural change in all patients with adverse lifestyles, also in the frame of modern cardiac rehabilitation and secondary prevention programmes. Conflict of interest: none declared. The opinions expressed in this article are not necessarily those of the Editors of the European Journal of Preventive Cardiology or of the European Society of Cardiology.