The effect of interventions onthe absolute probability of developing a CV event increases with anincreasing baseline risk; that is, the number of individuals neededto treat NNT to prevent one event decreases with increasing risk. The charts assist in risk estimation but must be interpreted in lightof the clinician's knowledge and experience and in view of thefactors that may modify the calculated risk see below. Relative risks may be high in young persons, even if 10 year absoluterisks are low, because events usually occur later in life. Therelative risk chart or estimating risk age may be helpful inidentifying and counselling such persons.
The lower risk in women is explained by the fact that risk isdeferred by 10 years—the risk of a year-old woman is similar tothat of a year-old man. Ultimately, more women than men die ofCVD. The charts may be used to give some indication of the effects ofreducing risk factors, given that there will be a time lag beforerisk reduces and that the results of RCTs in general give betterestimates of the benefits of interventions. Those who stop smokinggenerally halve their risk.
Apart from the conventional major CV risk factors included in the riskcharts, there are other risk factors that could be relevant for assessingtotal CVD risk. The Task Force recommends additional risk factor assessmentif such a risk factor improves risk classification [e. In very-high-risk or very-low-risk situations, the impact ofadditional risk factors is unlikely to alter management decisions. While thepresence of risk modifiers may move an individual's estimated risk upward,absence of these modifiers should lead to lowering an individual's estimatedrisk. Several otherfactors that are frequently discussed in the literature, but may not havethe ability to reclassify subjects, are discussed in subsequent paragraphs.
Also discussed further in this section are the roles of ethnicity and ofspecific conditions or diseases that may be associated with a higher thancalculated risk, such as CKD, autoimmune diseases, etc. The way modifiersare related to CV risk may be very different. Family history may reflect a shared environment, genetic factors or both. Markers such as computed tomography CT calcium scoring are indicators ofdisease rather than risk factors for future disease. The target can be higher in frail elderly, or lower in mostpatients with DM see chapter 3.
See section 3a. While accepting the simplicity of this approach and thatit could be useful in some settings, there is better scientificsupport for the three targets matched to level of risk. It should be noted that the evidence for patientswith CKD is less strong. Estimation of total CV risk remains a crucial part of the present guidelines. The priorities risk categories defined in this section are for clinicaluse and reflect the fact that those at highest risk of a CVD event gain mostfrom preventive measures. This approach should complement public actions toreduce community risk factor levels and promote a healthy lifestyle.
Theprinciples of risk estimation and the definition of priorities reflect anattempt to make complex issues simple and accessible. Their very simplicitymakes them vulnerable to criticism. The young, women, older people and ethnic minorities continue to beunderrepresented in clinical trials. A systematic comparison of current international guidelines is neededto define areas of agreement and the reasons for discrepancies. Family history of premature CVD in first-degree relatives, before 55years of age in men and 65 years of age in women, increases the riskof CVD.
Several genetic markers are associated with an increased risk of CVD,but their use in clinical practice is not recommended. Familial history of premature CVD is a crude but simple indicator of therisk of developing CVD, reflecting both the genetic trait and theenvironment shared among household members. A family history of premature CVD is simple, inexpensive information thatshould be part of the CV risk assessment in all subjects. Family historycan be a risk modifier to optimal management after the calculated riskusing SCORE lies near a decisional threshold: a positive family historywould favour more intensive interventions, while a negative familyhistory would translate into less intensive treatment.
Genetic screening and counselling is effective in some conditions, suchas familial hypercholesterolaemia FH see section 3a. Thisparagraph will focus on genetic screening for high CV risk in thegeneral population. Several recent genome-wide association studies have identified candidategenes associated with CVD. Since the effect of each genetic polymorphismis small, most studies have used genetic scores to summarize the geneticcomponent. There is a lack of consensus regarding which genes and theircorresponding single nucleotide polymorphisms SNPs should be includedin a genetic risk score and which method should be used to calculate thegenetic score.
The association of genetic scores with incident CVD has beenprospectively studied, adjusting for the main CV risk factors, and moststudies have found a significant association, with the relative risksvarying between 1. TheNRI is a statistical measure quantifying the usefulness of adding newvariables to a risk prediction equation. Currently, many commercial tests are available, allowing an almostcomplete assessment of an individual's genome, and strong pressure isbeing applied to use this information to predict genetic risk and tomake genetic testing a routine measure.
Epigenetics studies the chemical changes in DNA that affect geneexpression. Methylation of genes related to CV risk factors isassociated with variation in CV risk factor levels, 87 , 88 and lower DNA methylation levelsare associated with an increased risk of CAD or stroke. Thus, epigeneticscreening of CVD is not recommended. Future studies should assess the power of different genetic riskscores to improve CVD risk prediction in several differentpopulations, the number of events prevented and thecost-effectiveness of including genetic data in the riskassessment.
Low socio-economic status, lack of social support, stress at work andin family life, hostility, depression, anxiety and other mentaldisorders contribute to the risk of developing CVD and a worseprognosis of CVD, with the absence of these items being associatedwith a lower risk of developing CVD and a better prognosis ofCVD. Psychosocial risk factors act as barriers to treatment adherence andefforts to improve lifestyle, as well as to promoting health inpatients and populations. Low socio-economic status, defined as low educational level, low income,holding a low-status job or living in a poor residential area, confer anincreased risk of CAD; the relative risk RR of CAD mortality risk is1.
People who are isolated or disconnected from others are at increased risk ofdeveloping and dying prematurely from CAD. Acute mental stressors may act as triggers of acute coronary syndrome ACS. These stressors include exposure to natural catastrophes, as well aspersonal stressors e.
Chronic stress at work e. The NRI improved significantly. Meta-analyses reported a 1. Hostility is a personality trait, characterized by extensive experience ofmistrust, rage and anger and the tendency to engage in aggressive,maladaptive social relationships. A meta-analysis confirmed that anger andhostility are associated with a small but significant increased risk for CVevents in both healthy and CVD populations RR 1.
In most situations, psychosocial risk factors cluster in individuals andgroups. Mechanisms that link psychosocial factors to increased CV risk includeunhealthy lifestyle [more frequent smoking, unhealthy food choices and lessphysical activity PA ] and low adherence to behaviour changerecommendations or CV medication. Assessment of psychosocial factors in patients and persons with CV riskfactors should be considered for use as risk modifiers in CV riskprediction, especially in individuals with SCORE risks near decisionalthresholds.
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In addition, psychosocial factors can help identify possiblebarriers to lifestyle changes and adherence to medication. Standardizedmethods are available to assess psychosocial factors in many languages andcountries. The management ofpsychosocial risk factors should be addressed according to Chapter 3a. It remains unknown whether routine screening for psychosocial riskfactors contributes to fewer future cardiac events.
There is evidence of publication bias in the field of novelbiomarkers of CV risk, leading to inflated estimates of strength ofassociation and potential added value. In general, biomarkers can be classified into inflammatory e. However, for the purpose of overall CV riskestimation, these distinctions are generally not relevant.
Also, from theperspective of risk stratification i. Among the most extensively studied and discussed biomarkers is hsCRP. Thisbiomarker has shown consistency across large prospective studies as a riskfactor integrating multiple metabolic and low-grade inflammatory factors,with RRs approaching those of classical CV risk factors. However, itscontribution to the existing methods of CV risk assessment is probablysmall. Meta-analyses and systematic reviews suggest that the vast majority of othercirculating and urinary biomarkers have no or limited proven ability toimprove risk classification.
However, the extent to which they have beentested for their ability to add value to risk stratification variesconsiderably, , with strong evidence of reporting bias. If, despite these recommendations, biomarkers are used as risk modifiers, itis important to note that having an unfavourable biomarker profile may beassociated with a somewhat higher risk, but also that a favourable profileis associated with a lower risk than calculated. The degree to which thecalculated risk is affected by biomarkers is generally unknown, but almostuniversally smaller than the adjusted RRs reported for these biomarkers inthe literature.
Not all potentially useful circulatory and urinary biomarkers haveundergone state-of-the-art assessment of their added value in CVrisk prediction on top of conventional risk factors. Biomarkers may be useful in specific subgroups, but this has beenaddressed in only a limited number of studies. The role of metabolomics as risk factors for CVD and to improve CVrisk prediction beyond conventional risk factors should be furtherassessed. Routine screening with imaging modalities to predict future CV eventsis generally not recommended in clinical practice.
Imaging methods may be considered as risk modifiers in CV riskassessment, i. Although most CVD can be explained by traditional risk factors, there issubstantial variation in the amount of atherosclerosis. Thus interest hascontinued in the use of non-invasive imaging techniques to improve CV riskassessment. In individuals with calculated CV risks based on the majorconventional risk factors near the decisional thresholds, some imagingtechniques may be considered as risk modifiers to improve risk predictionand decision making. Calcifications indicate late-stage subclinical coronaryatherosclerosis.
The extent of the calcificationcorrelates with the extent of total coronary plaque burden. The quantification of CAC scoring is fairly consistent across studies. Most studies use the Agatston score. Although recent studies also showed the presence of CAC in low-riskpopulations, the added predictive value on CV events remains to bedemonstrated. There are concerns regarding costs and radiation exposure. Population-based studies have shown correlations between the severity ofatherosclerosis in one arterial territory and the involvement of otherarteries.
Risk assessment using carotidultrasound focuses on the measurement of the intima—media thickness IMT and the presence and characteristics of plaques. TheIMT-associated risk of cardiac events is also non-linear. The lack of standardization regarding the definition and measurement ofIMT, its high variability and low intra-individual reproducibility haveraised concerns.
Plaquesare related to both coronary and cerebrovascular events, and echolucent as opposed to calcified plaques increase ischaemic cerebrovascularevents. Therefore, even though formal reclassificationanalyses have not been undertaken, carotid artery plaque assessmentusing ultrasonography may be considered to be a risk modifier in CV riskprediction in some cases.
Arterial stiffness is commonly measured using either aortic pulse wavevelocity PWV or arterial augmentation index.
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An increase in arterialstiffness is usually related to damage in the arterial wall, as has beenshown in hypertensive patients. Ameta-analysis showed that arterial stiffness predicts future CVD andimproves risk classification. The ankle—brachial index ABI is an easy-to-perform and reproducibletest to detect asymptomatic atherosclerotic disease. The ABI is inversely related to CV risk, but there is controversyregarding its potential to reclassify patients into different riskcategories.
Echocardiography is more sensitive than electrocardiography in diagnosingleft ventricular hypertrophy LVH and it precisely quantifies leftventricular LV mass and geometric LVH patterns. Cardiac abnormalitiesdetected by echocardiography have an additional predictivepower. Currently, most imaging techniques have not been rigorouslytested as screening tools in CV risk assessment; more evidenceon calibration, reclassification and cost-effectiveness is stillneeded.
In addition, inflammatory mediators andpromoters of calcification cause vascular injury and may explain why CKDis associated with CVD even after adjustment for conventional riskfactors.
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End-stage renal disease isassociated with a very high CV risk. There is an association between acute respiratory infections,especially those occurring at times of peak influenza viruscirculation, and AMI. Influenza can trigger a CV event. Studies show an increase in rates of MIduring the annual influenza season.
The risk of MI or stroke was morethan four times higher after a respiratory tract infection, with thehighest risk in the first 3 days. Studies have linked periodontal disease to both atherosclerosis andCVD, , andserological studies have linked elevated periodontal bacteria antibodytitres to atherosclerotic disease.
Patients surviving cancer after treatment with chemotherapy orradiotherapy are at increased risk for CVD. The increased incidence of CVD is correlated with the combination of treatments given and the administered dose. Cardiotoxicity dueto chemotherapy is related to a direct effect on the cell anthracycline-like through the generation of reactive oxygen species ROS. Some agents fluorouracil, bevacizumab, sorafenib and sunitinib can induce a directischaemic effect not related to the premature development ofatherosclerotic lesions.
Moreover, they can increase risk factors suchas hypertension and accelerate atherosclerosis, especially in olderpatients. These effects can be irreversible type I agents or partiallyreversible type II agents and can develop many years after treatmentexposure. Typically, anthracyclines are the prototype of type I agentsand trastuzumab of type II agents. Cardiotoxicity due to chest radiotherapy can induce micro- andmacrovascular injury. It can accelerate atherosclerosis, but this mayoccur many years after the initial exposure. The first step in the identification of higher risk for cardiotoxicityconsists of a careful baseline assessment of CV risk factors.
Primarycare, cardiology and oncology should work together to deliver optimalsurvivorship care that addresses CVD risk factors as well as prevalentdisease. Positive health-promoting behaviour, including lifestylefactors healthy diet, smoking cessation, regular exercise, weightcontrol should be strongly advised. Signs or symptoms of cardiac dysfunction should be monitored before andperiodically during treatment for early detection of even asymptomaticabnormalities in patients receiving potentially cardiotoxicchemotherapy, and heart failure HF guideline recommendations should befollowed if indicated.
In the case of a decrease in LV function during or after chemotherapy,the use of cardiotoxic agents should be avoided or delayed, if possible,until after discussion with the oncology team. This calls for adequatecommunication between oncology and cardiology. Evidence on the effect of early preventive measures to reducetype I cardiotoxicity is inconclusive. The most appropriate strategy to improve risk stratification andprevent CVD in patients treated for cancer needs to be testedprospectively. There is mounting evidence that other immune diseases, such asankylosing spondylitis or early severe psoriasis, also increaseCV risk, with RRs approaching those in RA.
Post hoc analysis of two statin trials suggests that the relativereduction in CVD incidence in autoimmune diseases is comparableto that seen in the other conditions. There is now clear evidence implicating high-grade inflammation as apathway for accelerated vascular disease. Evidence in psoriasis is less rigorous, but a recent paper demonstratesbroadly comparable CV risks in RA and in early severepsoriasis. Hence, clinicaljudgment should be applied on a case-by-case basis. There is evidencefrom post hoc analysis of randomized trials to support astatin-associated reduction in CV risk in autoimmuneconditions.
Key message OSAS is characterized by recurrent partial orcomplete collapse of the upper airway during sleep. Treatment options include behavioural changes, such as avoiding alcohol,caffeine or other stimulants of wakefulness before sleep, increased PA,discontinuation of sedating drugs and obesity control. Continuouspositive airway pressure is the gold-standard therapy and reduces CVmortality and events. ED and CVD share common risk factors, including age,hypercholesterolaemia, hypertension, insulin resistance and DM, smoking,obesity, metabolic syndrome, sedentary lifestyle and depression.
CVD andED also share a common pathophysiological basis of aetiology andprogression.
Thorough history taking,including CV symptoms and the presence of risk factors and co-morbidconditions, assessment of ED severity and physical examination aremandatory first-line elements of investigation. Lifestyle changes areeffective in improving sexual function in men: these include physicalexercise, improved nutrition, weight control and smokingcessation. The benefit of routine screening for ED and the most effectivetool to assess it are still unclear. The most powerful driver of risk in all short-term 5 or 10 year CV riskalgorithms is age.
However, some younger individuals are at very high relative risk comparedwith individuals of a similar age and may have high lifetime risk: they aremore likely to develop CVD early and may prematurely suffer fatal ornon-fatal CV events. So trying to identify who may be at such risk is animportant challenge. There are no data on the right age to begincollecting such information in the general population, but someguidelines advocate starting at age 40 years.
However, in the absence of avery high individual risk factor level or diagnosis of FH, their yearrisk will never be high enough to warrant BP- or lipid-lowering therapy. There are no data on what are the mosteffective methods of changing health behaviours in younger people. However, smoking cessation, healthy weight maintenance and regularaerobic activity are all important behaviours on which to provide adviceand support.
Younger people with very high BP levels warranting treatment should bemanaged in the same way as older people with hypertension. In youngerpeople who are judged eligible for a statin on the grounds of either FHor very high lipid levels, the management offered is the same as forolder people. Very importantly, for all patients deemed to suffer withFH, the physician making the management decisions should arrange for FHscreening for family members see section 3a.
Age is the dominant driver of cardiovascular risk, and most individuals arealready at very high risk at the age of 65 years see section 2.
Especially in the oldest old, cardiovascular risk management iscontroversial. Opponents argue that risk should not be treated when it isessentially age-driven. Proponents, on the other hand, point out that manypreventive treatments are still effective at advanced age in terms ofpostponing morbidity and mortality. The Task Force has taken the position that epidemiological evidence ofabsolute risk reduction in clinical trials is the main driver forrecommendations in this guideline.
Still, we encourage a discussion withpatients regarding quality of life and life potentially gained, as well asregarding the ethical dilemmas of treating risk inherent to ageing, thetotal burden of drug treatment and the inevitable uncertainties ofbenefit. In this guideline, sections on treatment of the main risk factors containrecommendations or considerations specific to the elderly when evidence isavailable.
Most of the elderly-specific evidence is available for BP section 3a. In general, more lenient treatment targets are advocated in the elderly. The hypertension literature also contains increasing evidence thatbiological rather than calendar age is important. Evidence supporting more lenient glycaemic control targets in the elderlyis also available for DM section 3a. Few areas in CVD prevention are more controversial than the mass use ofstatins in the elderly.
On the other hand, thecost-effectiveness of statins in these patients is offset by even smallgeriatric-specific adverse effects. A recent trial suggested no harm of stopping statins in theelderly with a limited life expectancy. Several obstetric complications, in particular pre-eclampsia andpregnancy-related hypertension, are associated with a higher risk ofCVD later in life.
This higher risk is explained, at least partly,by hypertension and DM. Specific conditions that may occur in females only and may have an impact onCVD risk can be separated into obstetric and non-obstetric conditions. Studies suggest thatpre-eclampsia is associated with an increase in CV risk by a factor1.
The rationale for screening these women for theoccurrence of hypertension and DM is, however, quite strong. The risk of developing DM is probablyalso elevated in these women, but exact estimates are not available. There are no data to suggest that recurrent pregnancy loss is associatedwith an increased CV risk. PCOS has beenassociated with an increased risk for future development of CVD, butlarger studies have produced conflicting results. There are insufficient data to draw conclusions on apossible increased risk of hypertension or DM. The degree to which increased CVD risk associated with several ofthe female-specific conditions occurs independent ofconventional CVD risk factors is unknown.
Information on whether female-specific conditions improve riskclassification in women is unknown. CVD risk varies considerably between immigrant groups. Current risk estimation equations do not provide adequate estimationsof CVD risk in ethnic minorities. First-generation migrants usually display lower CVD mortality rates thannatives of the host country, but with time, migrants tend to approach the CVDrisk in their host country.
Immigrants from South Asia notably India and Pakistan present high CVDrates — and have a much higher prevalence ofDM, , while theprevalence of other CV risk factors is slightly lower than or comparable tonatives of the host country. Management of DM is alsosignificantly worse, while management of high BP and hypercholesterolaemiais better among South Asians than host country natives.
Immigrants from China and Vietnam present lower CVD risk than natives of thehost country, although this finding has been challenged. This seems mainly due to the higher prevalence ofsmoking, DM, dyslipidaemia, hypertension and obesity rates. Immigrants from Morocco present lower CVD rates than natives from the hostcountry.
Immigrants from sub-Saharan Africa and the Caribbean present higher CVD ratesthan natives from the host country in some studies, , , but not all. Management of CVD risk factors was worsethan among natives in one study, but not in another. Based on available mortality and prospective data, the following correction factorscould be applied when assessing CVD risk using SCORE among first-generationimmigrants only. These values reflect the best estimations from availabledata and should be interpreted with caution, but can be used to guide CVrisk management.
Alternatively, ethnicity-specificCVD risk equations should be developed. Cognitive behavioural methods are effective in supporting persons inadopting a healthy lifestyle. Individual and environmental factors impedethe ability to adopt a healthy lifestyle, as does complex or confusing advicefrom caregivers. It is important to explore each patient's experiences,thoughts, worries, previous knowledge and circumstances of everyday life.
Individualized counselling is the basis for motivation and commitment. Decision-making should be shared between the caregiver and patient includingalso the individual's spouse and family. In addition, caregivers can build on cognitive behavioural strategies to assessthe individual's thoughts, attitudes and beliefs concerning the perceivedability to change behaviour, as well as the environmental context.
Previous unsuccessful attempts often affect self-efficacy for future change. Acrucial step is to help set realistic goals combined with self-monitoring of thechosen behaviour. Combining the knowledge and skills of caregivers such as physicians, nurses,psychologists, experts in nutrition, cardiac rehabilitation and sports medicine into multimodal behavioural interventions can optimize preventiveefforts.
There is limited evidence to determine which interventions are mosteffective in specific groups e. Treatment of psychosocial risk factors can counteract psychosocialstress, depression and anxiety, thus facilitating behaviour change andimproving quality of life and prognosis. The caregiver—patient interaction should follow the principles ofpatient-centred communication.
Age- and sex-specific psychosocialaspects should be considered. Caregivers in clinical practice are in a unique position to directly supporttheir patients regarding psychosocial risk factors in individuals with high CVrisk or with established disease. Empathic, patient-centred communication helpsto establish and maintain a trustful relationship and is a powerful source ofemotional support and professional guidance in coping with psychosocialstressors, depression, anxiety, CV risk factors and CVD. Explain essential medical facts in the patient's own language, conveyhope and relief from feelings of guilt and reinforce adaptive thoughtsand actions.
In the case of severe mental symptoms, obtain treatment preferences andperform shared decision-making regarding further diagnostic andtherapeutic steps. In addition to the treatment of mood symptoms, there are several other approachesto psychosocial intervention that have proved useful. Two RCTs , have shown the favourable impact ofstress management and social support groups on the prognosis of clinical CAD.
Nurse-led interventions reveal beneficial effects on anxiety, depression andgeneral well-being in CAD patients. In hostile CAD patients, a group-based hostility-control intervention may leadnot only to decreases in behaviourally assessed hostility levels, but also todecreased levels of depression, resting heart rate HR and CV reactivity tomental stress, as well as to increased social support and satisfaction withlife. Hence, a reduction of work stress in managers and supervisors mayhave beneficial health effects on the target individuals and may also improveperceived social support in their subordinates.
Evidence that treatment of clinically significant depression and anxietyalone will prevent CVD and improve outcomes is inconclusive. Health providers should assess the PA level in any subject how many days andminutes per day are spent on average doing PA at moderate or vigorousintensity. They should warn against inactivity and help add PA to dailylife.
Subjects should be advised on appropriate types of activities and waysof progressing and should be helped to set personal goals to achieve andmaintain the benefits. For a moreeffective behaviour change, clinicians should explore practical ways toovercome barriers to exercise. For this reason, the link between primarycare and local community-based structures for activity, recreation and sportis crucial. Aerobic PA, the most studied and recommended modality, with a beneficialdose—response effect on prognosis, , , consists of movements of largemuscle mass in a rhythmic manner for a sustained period.
It includeseveryday activity, including active travel cycling or walking , heavyhousehold work, gardening, occupational activity and leisure timeactivity or exercise such as brisk walking, Nordic walking, hiking,jogging or running, cycling, cross-country skiing, aerobic dancing,skating, rowing or swimming.
Similar to all other interventions, its prescription can be adjusted interms of frequency, duration and intensity. However, practising PA belowthe lowest recommended levels should be encouraged in individuals unableto meet the minimum or in those sedentary individuals who have juststarted, with a gradual increase in activity level. Moderate or vigorous aerobic exercise should be recommended.
This can beexpressed either in absolute or relative terms. By convention thiscorresponds to 3. Relative intensity is the level of effort required toperform an activity. Less fit individuals generally require a higherlevel of effort than fitter people to perform the same activity. Forindividuals on medication, it is important to consider possiblemodification of HR response and to refer to other relative intensityparameters. Especially for older and deconditioned individuals, arelative measure of intensity is more appropriate. Classification of physical activity intensity and examples ofabsolute and relative intensity levels.
Modified from Howley. PA should occur at a frequency of at least three to five sessions perweek, but preferably every day. Shorterexercise sessions i. Aerobic interval training and high-intensity interval training cannot yetbe broadly recommended until further data on safety and efficacy areavailable.
Isotonic PA stimulates bone formation and reduces bone loss; it preservesand enhances muscle mass, strength, power and functional ability, withsome evidence of benefit in lipid and BP control and insulinsensitivity, especially in combination with aerobic exercise. For older adults at risk of falls, neuromotor exercise helps to maintainand improve balance and motor skills balance, agility, coordination andgait. This includes multifaceted activities such as tai chi and yoga,and recreational activities using paddles or sport balls to challengehand—eye coordination.
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The optimal volume is not known. Progressive warm-up before and cool-downafter exercise may prevent injuries and adverse cardiac events. With the improvement in exercise tolerance, each subjectprogresses in the level of PA, but increases in any components i. Before starting more intensive leisure time activities i. Clinical evaluation, including exercise testing, may beconsidered for sedentary people with CV risk factors who intend to engage invigorous PA and sports.
The information gathered from exercise tests may beuseful in establishing a safe and effective exercise prescription. Validatedself-assessment questionnaires have been proposed for sedentary individualsentering low-intensity leisure time sports activity or startingmoderate-intensity activities see Table B in web addenda. The lower and upper limit of aerobic PA intensity, duration andfrequency to exert a beneficial effect is unknown.
The effectiveness of PA monitoring vs. There is a strong evidence base for brief interventions with advice tostop smoking, all types of nicotine replacement therapy NRT ,bupropion, varenicline and greater effectiveness of drugs incombination, except for NRT plus varenicline. The most effective arebrief interventions plus assistance with stopping using drug therapy andfollow-up support. Electronic cigarettes e-cigarettes may help in smoking cessation butshould be covered by the same marketing restrictions as cigarettes.
Smoking is a lethal addictive disorder. The year fatal CVD risk is approximately doubled insmokers. Slightly less than half of lifetime smokers will continue smoking untildeath. Store Categories. Store home. Raw Grey, Rectified Grey Mix. Note: Variations in color, shade, and tone are natural for all tiles and mosaics Colors may vary due to individual monitor profile settings Design Industry is the new multi-material collection inspired by urban design and contemporary architectural trends.
This listing is for an 8" x 8" Sample of the full 24" x 24" tile. Visit our Mosaic Gallery! Shipping and handling. The seller has not specified a shipping method to Germany. Contact the seller - opens in a new window or tab and request shipping to your location. Shipping cost cannot be calculated. Please enter a valid ZIP Code. Shipping to: United States. No additional import charges at delivery! This item will be shipped through the Global Shipping Program and includes international tracking. Learn more - opens in a new window or tab. There are 39 items available.
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Payment details. Payment methods. Other offers may also be available. Interest will be charged to your account from the purchase date if the balance is not paid in full within 6 months. Minimum monthly payments are required. Subject to credit approval. See terms - opens in a new window or tab. Back to home page Return to top. Open in a separate window. Figure 1. Figure 2. Stage 2 The characteristics of the Stage 2 studies, including the genotyping and imputation approaches, are described in Supplementary Tables 1A and 1B and the details of corrections for treatment described in the Supplementary Note.
Pooled analysis of first and second stage samples Meta-analysis from stages 1 and 2 was conducted using inverse variance weighting and genomic control applied. Supplementary Material 1 Click here to view. Footnotes Competing Financial Interests A. References 1. Ehret G, et al. Levy D, et al. Genome-wide association study of blood pressure and hypertension.
Newton-Cheh C, et al. Genome-wide association study identifies eight loci associated with blood pressure. Lawes CM, et al. Blood pressure and the global burden of disease Part II: estimates of attributable burden. J Hypertens. Rose G. Strategies of prevention: the individual and the population. In: Marmot M, E P, editors.
Coronary heart disease epidemiology: From aetiology to Public health. Oxford University Press; Oxford: Domanski MJ, et al. Independent prognostic information provided by sphygmomanometrically determined pulse pressure and mean arterial pressure in patients with left ventricular dysfunction. J Am Coll Cardiol. Domanski M, et al. Franklin SS, et al. Single versus combined blood pressure components and risk for cardiovascular disease: the Framingham Heart Study.
Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Devlin B, Roeder K. Genomic control for association studies. Kato N, et al. Meta-analysis of genome-wide association studies identifies common variants associated with blood pressure variation in east Asians. Sesso HD, et al. Systolic and diastolic blood pressure, pulse pressure, and mean arterial pressure as predictors of cardiovascular disease risk in Men. Pulsatile versus steady component of blood pressure: a cross-sectional analysis and a prospective analysis on cardiovascular mortality.
Blacher J, Safar ME. Large-artery stiffness, hypertension and cardiovascular risk in older patients. Nat Clin Pract Cardiovasc Med. Pulse pressure--a review of mechanisms and clinical relevance. Johnson AD, et al. Genome-wide meta-analyses identifies seven loci associated with platelet aggregation in response to agonists. Soranzo N, et al. A novel variant on chromosome 7q A genome-wide meta-analysis identifies 22 loci associated with eight hematological parameters in the HaemGen consortium. Oudit GY, et al. Phosphoinositide 3-kinase gamma-deficient mice are protected from isoproterenol-induced heart failure.
Perrino C, et al. Dynamic regulation of phosphoinositide 3-kinase-gamma activity and beta-adrenergic receptor trafficking in end-stage human heart failure. Wagsater D, et al. ADAMTS-4 and -8 are inflammatory regulated enzymes expressed in macrophage-rich areas of human atherosclerotic plaques. Nov gene encodes adhesion factor for vascular smooth muscle cells and is dynamically regulated in response to vascular injury.
Arterioscler Thromb Vasc Biol. Shimoyama T, et al. CCN3 inhibits neointimal hyperplasia through modulation of smooth muscle cell growth and migration. Heath E, et al. Abnormal skeletal and cardiac development, cardiomyopathy, muscle atrophy and cataracts in mice with a targeted disruption of the Nov Ccn3 gene. BMC Dev Biol. Cools J, et al. Kamatani Y, et al. Genome-wide association study of hematological and biochemical traits in a Japanese population.