Editor’s presentation

The factors associated with emotional distress were assessed in 27,267 consecutive patients with their first myocardial infarction (MI) from the SWEDEHEART registry: symptoms of emotional distress were prevalent in 33% of patients at 12 months. Previous emotional distress (especially depression and anxiety), female sex, young age, smoking, being immigrant, neither employed nor retired, and having readmissions for major cardiovascular events were all strongly related with emotional distress post-MI.1 In this respect the role of cardiac rehabilitation with regular physical activity promotion should not be overlooked2 to reduce emotional distress and major adverse clinical outcomes.3 Suboptimal cardiovascular risk management in patients with coronary and non-coronary atherosclerosis is well known,4,5 which is associated with an inflammatory response. There is recent evidence that modulation of a key inflammatory pathway in atherosclerosis can reduce clinical events. In the present issue, a cross-sectional study identified that 39% of a coronary heart disease population were at elevated inflammatory risk as defined by a high sensitivity C-reactive protein level (≥2 mg/L). Interestingly, daily smoking and higher body mass index were independently associated with high inflammatory risk. The majority of those with increased inflammatory risk had low-density lipoprotein cholesterol levels not at target (≥1.8 mmol/L).6 The authors suggested improving cardiovascular risk management before considering inflammatory pathway modulation.7 In this regard, a consensus document from the Working Group of Atherosclerosis and Vascular Biology of the European Society of Cardiology addresses the close connections between hypercholesterolaemia and inflammation, concerning their synergistic biological contributions to atherosclerosis, and also their specific therapies, which now seem to be complementary approaches to reduce cardiovascular risk. We have gained extensive knowledge about which interventions are suitable for cardiovascular prevention to enhance health literacy8 and that low health literacy tends to cluster with various cardiovascular risk factors:9 however, guideline recommendations on risk factors are poorly implemented in clinical practice.10 In this issue, a multinational study group found, based on data from >700 patients in families with familial hypercholesterolaemia, marked national differences with respect to health literacy, with more inadequate levels of health literacy in China (37%), Malaysia (25%) and Brazil (22%) compared with the UK (7%), Australia (19%), Hong Kong (16%) and Taiwan (18%). Low health literacy was strongly associated with higher age and lower levels of education or income, and the latter was an independent predictor for low health literacy even when adjusted for age.11 The authors concluded that interventions should take the higher educational needs of these patients into account. In keeping with these findings, in a large cohort of more than 29,000 survivors of a first MI, the first recurrent manifestation of atherosclerotic cardiovascular disease was predicted by disposable income, level of education and marital status.12 The association between disposable income and first recurrent manifestation of atherosclerotic cardiovascular disease was independent of secondary preventive treatment. A comprehensive analysis of temporal trends of a large number of patients from Poland treated for MI with depressed left ventricular (LV) function is presented. Fewer recurrent MIs were observed, but heart failure rehospitalizations and all-cause mortality did not decrease. After adjustment for sex and age, all-cause mortality and composite outcomes (death, MI, stroke or heart failure rehospitalization) revealed a significant decreasing trend. However, the authors observed that only 25% of the population followed a rehabilitation programme, while the ‘benchmark’ is 40%, which has been shown to favourably affect prognosis.13,14 In 76 young cross-country skiers (<13 years of age) who followed an intense training regime (seven hours per week) for a mean of five years, with respect to matched controls, echocardiography tests showed increased LV mass, and left and right ventricular enlargement, while three-dimensional ejection fraction and longitudinal and circumferential strain remained normal. In this area, large controversy still exists: for example, while there is recent evidence that the physiological remodelling in athlete’s heart does not permanently affect LV deformation,15 overtraining in itself has been implicated in the genesis arrhythmias through irreversible cardiac changes.16 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.