Editor’s presentation

The differential effect of treatment on cardiovascular risk factor levels and outcomes according to ethnicity has been suggested previously.1,2 This finding has been confirmed in a sub-analysis of the HOPE-3 trial. The results in the study population, stratified according to Asian and non-Asian ethnicity, showed several striking features: first, decreases in both blood pressure and low-density lipoprotein cholesterol levels were lower among Asians. Second, despite similar benefits regarding the reduction of both co-primary endpoints, the reduction was stronger for strokes in Asians and for myocardial infarction in non-Asians. Third, treatment by rosuvastatin increased the risk of incident diabetes in non-Asians only. Characteristic response to exercise and haemodynamic response have been described in diabetes.3 More importantly, the lack of effective preventive measures with the consequent presence of obesity and sedentary habit negatively affect prognosis in diabetes mellitus and give a 10-fold increased risk for major adverse cardiovascular events.4 In the present issue, two papers are dedicated to this important topic. In the first, entitled “Exercise training to reduce cardiovascular risk in patients with metabolic syndrome and type 2 diabetes mellitus: How does it work?”, the molecular and cellular mechanisms underlying the effects of exercise training on cardiovascular risk, specifically in patients with metabolic syndrome and diabetes, are revised. The pleiotropic effects, and the benefits not only to metabolic but also to cardiovascular endpoints are discussed. The second paper is an official document of the European Association of Preventive Cardiology (EAPC), which provides recommendations for the prescription of exercise training in patients with both type 2 diabetes mellitus and cardiovascular disease. The writing task force first reviewed the literature on the role of different exercise modalities, taking into consideration, type, intensity and duration.5 Thereafter, different exercise programmes depending on the individual target parameter are considered. Finally, practical recommendations on the modalities of the implementation of exercise and how to tackle the barriers are presented. Exercise stress testing (EST) is a common tool in cardiology and sports medicine6: the most common parameters used for decision-making during EST include maximal theoretical heart rate (MTHR). However, this parameter is highly influenced by the exercise modality or body composition. A cross-sectional study performed among 460 adult professionals participating in a screening programme in the Ferrari Factory in Maranello (Italy) was carried out to assess the clinical significance of the common EST endpoints. Submaximal exercise testing (i.e. MTHR <85%) showed a low diagnostic power – that is, half of the ECG events remained undetected and 35% of the cardiovascular abnormalities observed at the diagnostic follow-up remained undiagnosed. Thus, terminating EST before volitional exhaustion limited the test accuracy and the possibility to detect cardiovascular abnormalities in apparently healthy adult populations. In contrast to secondary prevention, in primary prevention the role of the use of acetylsalicylic acid has been controversial.7 Furthermore, adherence to guidelines in aspirin prescription also remains a matter of debate.8 The recent ARRIVE9 study on the use of acetylsalicylic acid for the primary prevention of cardiovascular diseases did not show any advantages of using aspirin in a setting of recorded cardiovascular events which were well below expectations, underlining that this population was properly treated regarding antihypertensive and hypolipidaemic drugs, known for their cardioprotective effect. The meta-analysis presented here is in keeping with these results, observing a significant reduction in non-fatal myocardial infarction and ischaemic stroke in participants taking aspirin. However, the study did not find a significant difference in cardiovascular disease death, all-cause mortality and non-fatal stroke. Moreover, the authors found a significant increment in the rates of major bleeding, and major gastrointestinal bleeding in patients who received aspirin, but no significant difference in the rate of haemorrhagic stroke. In 1995, the US National Health and Nutrition Survey (2001–2004) observed an independent and strong association between serum vitamin D levels and cardiorespiratory fitness (CRF) in participants. Several lines of evidence support the biological plausibility of a potential role of vitamin D in CRF. A lower temperature was associated with lower vitamin D levels, which might contribute to the excess of cardiovascular events during the winter months. Other studies found that the prevalence of self-reported coronary artery disease and heart failure was lower in participants with higher vitamin D levels.10 Patients with an implantable cardioverter defibrillator (ICD) have been traditionally considered not eligible to engage in competitive sports activity, except for disciplines characterised by having a low cardiovascular demand. However, despite these ample theoretical reasons to restrict athletes with ICDs from sports participation, there are conflicting viewpoints on the eligibility of ICD carriers to engage in sport activities.11,12 In this issue, data from the ICD Sports Safety Registry showed that participants in recreational sports had less frequent appropriate and inappropriate shocks during physical activity than participants in competitive sports. Nonetheless, shocks did not cause death, bodily harm or accelerated lead malfunction, and the majority of athletes continued their sports activities after activity-related shocks. Therefore, recreational athletes with ICDs can safely engage in sports unless other reasons preclude continuation, such as concerns about progression of the underlying disease induced by physical activity, or psychological coping. 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.