Conference News Roundup—European Society of Cardiology

Low Socioeconomic Status Associated With Higher Risk of Second Heart Attack or Stroke
Low socioeconomic status is associated with a higher risk of a second heart attack or stroke, according to Joel Ohm, MD, a physician at the Karolinska University Hospital and Karolinska Institute in Stockholm. The study of nearly 30,000 patients with a prior heart attack revealed that the risk of a second event was 36% lower for those in the highest income quintile, compared with the lowest, and increased by 14% in divorced patients, compared with married patients.

"Are you rich or poor? Married or divorced? That might affect your risk of a second heart attack or stroke," said Dr. Ohm. "Advances in prevention and acute treatment have increased survival after heart attack and stroke over the past several decades. The result is that more people live with cardiovascular disease in Sweden. Almost one-fifth of the total population is in this group."

Most research on cardiovascular prevention is based on healthy people, and it is unclear whether the findings apply to patients with established disease. An association between socioeconomic status in healthy individuals and future cardiovascular disease was found in the 1950s. This study investigated the link between socioeconomic status in patients who had survived a first heart attack and the risk of a second heart attack or a stroke.

The study included 29,953 patients from the Swedish nationwide registry, Secondary Prevention after Heart Intensive Care Admission (SEPHIA), who had been discharged approximately one year previously from a cardiac intensive care unit after treatment for a first myocardial infarction. Data on outcome over time and socioeconomic status (defined as disposable income, marital status, and level of education) was obtained from Statistics Sweden and the National Board of Health and Welfare.

During an average follow-up of four years, 2,405 patients (8%) had a heart attack or stroke. After adjustments for age, gender, smoking status, and the defined measures of socioeconomic status, being divorced was independently associated with a 14% greater risk of a second event, compared with being married. There was an independent and linear relationship between disposable income and the risk of a second event, with those in the highest quintile of income having a 36% lower risk than those in the lowest quintile. A higher level of education was associated with a lower risk of events, but the association was not significant after adjustment for income.

"Our study shows that in the years following a first myocardial infarction, men and women with low socioeconomic status have a higher risk of suffering another heart attack or stroke. This is a new finding and suggests that socioeconomic status should be included in risk assessment for secondary prevention after a heart attack," said Dr Ohm. "Even though health care providers are unlikely to keep track of their patients' yearly salary, simple questions about other socioeconomic variables such as marital status and educational level could make a difference."

According to the widely used assessment tools for cardiovascular risk, survivors of heart attacks are at the highest possible risk for subsequent events, regardless of other risk factors. There is, for example, no difference in the estimated risk level between a previously healthy 40-year old female from Spain and a heavily smoking, obese, elderly man with diabetes and high blood pressure from Finland.

"Risk assessment tools are designed for individuals without previous cardiovascular disease, and the calculations may not apply to patients with established cardiovascular disease. Socioeconomic status is perhaps a better marker to assess risk of future events in heart attack patients, and more research is needed to determine other factors that could be included, such as occupation or residential area," said Dr Ohm.

Alcohol-Related Hospitalization Associated With Doubled Stroke Risk in Atrial Fibrillation
Alcohol-related hospitalization is associated with a doubled risk of ischemic stroke in patients with nonvalvular atrial fibrillation (AF), according to research presented by Faris Al-Khalili, MD, PhD, a cardiologist at the Karolinska Institute Danderyd Hospital in Stockholm. The observational study was conducted in more than 25,000 patients with nonvalvular AF at low risk of stroke.

"AF is the most common heart rhythm disturbance and is associated with a fivefold ncreased risk of ischemic stroke," said Dr. Al-Khalili. "AF is also associated with increased mortality, reduced quality of life, and a higher risk of heart failure."

Treatment with oral anticoagulants reduces the risk of stroke and is recommended according to the patient's number of stroke risk factors. Risk is estimated using the CHA2DS2-VASc score, which gives points for clinical risk factors. Patients with nonvalvular AF under age 65 who have a score of zero (in men) or one (in women) are considered to be at low risk for ischemic stroke, and oral anticoagulation therapy is not indicated for them.

"Even if the risk for stroke is low, it is not negligible, and a number of such low-risk patients do present with ischemic stroke in clinical practice and in patient registers," said Dr. Al-Khalili.  

The objective of this study was to assess the incidence and predictors of ischemic stroke among low-risk patients with nonvalvular AF. This retrospective study included 25,252 patients (ages 18 to 64) of a total of 34,523 patients with AF identified from the Swedish nationwide patient register for the period between January 1, 2006 and December 31, 2012. The median age was 55, and 72% of participants were men.

Information was available regarding  all hospitalizations and visits to hospital-affiliated open clinics in Sweden. Socioeconomic variables were obtained from a database for health insurance and labor market studies. Information about current medication was obtained from the National Drug Register, which has information about all dispensed prescription in Sweden and is 100% complete.

During a median follow-up of five years, ischemic stroke occurred at an annual rate of 3.4 per 1,000 patient-years. The overall mortality was 7.5 per 1,000 patient-years in patients without ischemic stroke and 29.6 per 1,000 patient-years in patients who had had an ischemic stroke during follow-up.

In the multivariable analysis, the only variables that remained significantly associated with an increased risk of ischemic stroke were age (hazard ratio [HR], 1.06) and alcohol-related hospitalization (HR, 2.01). Use of oral anticoagulants was associated with a lower risk of ischemic stroke (HR, 0.78).

"Even though these patients are classified as low-risk, the incidence of ischemic stroke in our study population is neither negligible nor ignorable, and it carries a relatively high mortality," said Dr. Al-Khalili.

"Previous studies have shown a causal and dose-response relation between alcohol and AF. Our study found that alcohol is an independent risk factor for stroke in patients with AF. Alcohol might induce AF, leading to embolic stroke, or there could be a specific alcohol effect that causes systemic or cerebral thromboembolism. Using alcohol-related hospitalization as a proxy for alcohol abuse likely underestimates the extent of the problem and does not allow grading of the amount of alcohol consumed.

"Doctors should ask their AF patients about alcohol use and advise patients to cut down if they are drinking more than is recommended. The beneficial link between oral anticoagulant use and ischemic stroke in this low-risk population without a recognized indication for these drugs needs further investigation, including the benefit to harm (bleeding) ratio," Dr. Al-Khalili concluded.

New Oral Anticoagulants Provide Same Stroke Prevention as Warfarin But Cause Less Bleeding
The new oral anticoagulants provide the same stroke prevention as warfarin, but cause less intracranial bleeding, according to research presented by Laila Staerk, PhD, a research fellow at Herlev and Gentofte University Hospital in Hellerup, Denmark.

"Atrial fibrillation is the most common cardiac rhythm disorder and currently affects more than 10 million Europeans," said Dr. Staerk. "Atrial fibrillation is associated with a fivefold risk of stroke, potentially leading to disability and death. In the next four decades, the number of patients with atrial fibrillation is expected to triple, so the number of Europeans diagnosed could rise to a staggering 25 to 30 million."

Patients with atrial fibrillation are treated life-long with oral anticoagulation to reduce their risk of stroke. But treatment with non-vitamin K antagonist oral anticoagulants (NOACs) and vitamin K antagonists (eg, warfarin) lowers the risk of stroke at the cost of increased bleeding risk.  

Several treatment options are available, and physicians may be unsure about which one to use. "There has been a need to investigate the safety and effectiveness of NOACs versus warfarin in a real-world population, and our Danish registries provide this opportunity," said Dr. Staerk.

The current study compared the risk of stroke and intracranial bleeding associated with NOACs (ie, dabigatran, rivaroxaban, and apixaban) versus that associated with warfarin in a real-world setting. The study was conducted at the Cardiovascular Research Centre at Herlev and Gentofte University Hospital. It included 43,299 patients with atrial fibrillation who were recruited from Danish nationwide administrative registries.

Approximately 42% of patients were taking warfarin, while 29%, 16%, and 13% were taking dabigatran, apixaban, and rivaroxaban, respectively. During follow-up, stroke occurred in 1,054 patients, and there were 261 intracranial bleedings.

The risk of having a stroke within one year was similar between the NOAC and warfarin groups and ranged from 2.0% to 2.5%. At one year, the risk of intracranial bleeding was significantly lower in patients treated with dabigatran and apixaban (0.3% to 0.4%), compared with that in those treated with warfarin (0.6%).

"The inclusion and exclusion criteria in our study were broadly similar for patients initiating NOACs or warfarin, and this gave a straightforward opportunity to directly compare the treatment regimens, which is in contrast to the randomized trials. The results suggest that although they have similar effects in preventing stroke, dabigatran and apixaban were associated with a safer use regarding the absolute one-year risk of intracranial bleeding," said Dr Staerk. "Our results complement the large randomized phase III trials by providing real-world data on stroke and intracranial bleeding with NOACs versus warfarin, since fragile patients were not excluded from our nationwide cohort. For example, patients with increased risk of bleeding, liver disease, and chronic kidney disease are less represented in trials."

"Registry studies have some limitations such as the observational design, residual confounding, and confounding by drug indication. In the future, it would be exciting to see a head-to-head randomized trial performed to compare the different NOAC treatments in patients with atrial fibrillation," said Dr Staerk.

Moderate Physical Activity Reduces Risk of Cardiovascular Death
Moderate physical activity is associated with a greater than 50% reduction in cardiovascular death in people older than 65, according to Riitta Antikainen, MD, Professor of Geriatrics at the University of Oulu in Finland. "These results prompt us to investigate the mechanisms through which the Mediterranean diet may protect against death," she said.

The 12-year study in nearly 2,500 adults between ages 65 and 74 found that moderate physical activity reduced the risk of an acute cardiovascular event by more than 30%. High levels of physical activity led to greater risk reductions.

"The role of physical activity in preventing cardiovascular disease [CVD] in people of working age is well established," said Dr. Antikainen. "But relatively little is known about the effect of regular physical activity on CVD risk in older people."

The present study assessed the association between leisure time physical activity and CVD risk and mortality in 2,456 men and women who were enrolled into the National FINRISK Study between 1997 and 2007.

Baseline data collection included self-administered questionnaires on physical activity and other health related behavior, clinical measurements (eg, blood pressure, weight, and height), and laboratory measurements, including serum cholesterol. Participants were followed up until the end of 2013. Deaths were recorded from the National Causes of Death Register, and incident CVD events (ie, coronary heart disease and stroke) were collected from the National Hospital Discharge register.

The researchers classified self-reported physical activity as low, moderate, or high. Low physical activity included reading, watching TV, and working in the household without much physical activity. Moderate physical activity encompassed walking, cycling, or practicing other forms of light exercise (eg, fishing, gardening, hunting) for at least four hours per week. High physical activity included recreational sports (eg, running, jogging, skiing, gymnastics, swimming, or ball games) or intense training or sports competitions for at least three hours per week.  

During a median follow-up of 11.8 years, 197 participants died from CVD, and 416 had a first CVD event.

When the researchers assessed the link between physical activity and outcome, they adjusted for other cardiovascular risk factors (ie, blood pressure, smoking, and cholesterol) and social factors (ie, marital status and education). To minimize reverse causality, where worse health leads to less physical activity, patients with coronary heart disease, heart failure, cancer, or prior stroke at baseline were excluded from the analysis.

The investigators found that moderate and high leisure-time physical activity were associated with a 31% and 45% reduced risk of an acute CVD event, respectively. Moderate and high leisure-time physical activity were associated with a 54% and 66% reduction in CVD mortality, respectively.

"Our study provides further evidence that older adults who are physically active have a lower risk of coronary heart disease, stroke, and death from cardiovascular disease. The protective effect of leisure time physical activity is dose dependent. In other words, the more you do, the better. Activity is protective even if you have other risk factors for cardiovascular disease such as high cholesterol," said Dr. Antikainen.  

"Physical exercise may become more challenging with aging. However, it is important for older people to still get enough safe physical activity to stay healthy after their transition to retirement."         

Low Socioeconomic Status Associated With Higher Risk of Second Heart Attack or Stroke
Low socioeconomic status is associated with a higher risk of a second heart attack or stroke, according to Joel Ohm, MD, a physician at the Karolinska University Hospital and Karolinska Institute in Stockholm. The study of nearly 30,000 patients with a prior heart attack revealed that the risk of a second event was 36% lower for those in the highest income quintile, compared with the lowest, and increased by 14% in divorced patients, compared with married patients.

"Are you rich or poor? Married or divorced? That might affect your risk of a second heart attack or stroke," said Dr. Ohm. "Advances in prevention and acute treatment have increased survival after heart attack and stroke over the past several decades. The result is that more people live with cardiovascular disease in Sweden. Almost one-fifth of the total population is in this group."

Most research on cardiovascular prevention is based on healthy people, and it is unclear whether the findings apply to patients with established disease. An association between socioeconomic status in healthy individuals and future cardiovascular disease was found in the 1950s. This study investigated the link between socioeconomic status in patients who had survived a first heart attack and the risk of a second heart attack or a stroke.

The study included 29,953 patients from the Swedish nationwide registry, Secondary Prevention after Heart Intensive Care Admission (SEPHIA), who had been discharged approximately one year previously from a cardiac intensive care unit after treatment for a first myocardial infarction. Data on outcome over time and socioeconomic status (defined as disposable income, marital status, and level of education) was obtained from Statistics Sweden and the National Board of Health and Welfare.

During an average follow-up of four years, 2,405 patients (8%) had a heart attack or stroke. After adjustments for age, gender, smoking status, and the defined measures of socioeconomic status, being divorced was independently associated with a 14% greater risk of a second event, compared with being married. There was an independent and linear relationship between disposable income and the risk of a second event, with those in the highest quintile of income having a 36% lower risk than those in the lowest quintile. A higher level of education was associated with a lower risk of events, but the association was not significant after adjustment for income.

"Our study shows that in the years following a first myocardial infarction, men and women with low socioeconomic status have a higher risk of suffering another heart attack or stroke. This is a new finding and suggests that socioeconomic status should be included in risk assessment for secondary prevention after a heart attack," said Dr Ohm. "Even though health care providers are unlikely to keep track of their patients' yearly salary, simple questions about other socioeconomic variables such as marital status and educational level could make a difference."

According to the widely used assessment tools for cardiovascular risk, survivors of heart attacks are at the highest possible risk for subsequent events, regardless of other risk factors. There is, for example, no difference in the estimated risk level between a previously healthy 40-year old female from Spain and a heavily smoking, obese, elderly man with diabetes and high blood pressure from Finland.

"Risk assessment tools are designed for individuals without previous cardiovascular disease, and the calculations may not apply to patients with established cardiovascular disease. Socioeconomic status is perhaps a better marker to assess risk of future events in heart attack patients, and more research is needed to determine other factors that could be included, such as occupation or residential area," said Dr Ohm.

Alcohol-Related Hospitalization Associated With Doubled Stroke Risk in Atrial Fibrillation
Alcohol-related hospitalization is associated with a doubled risk of ischemic stroke in patients with nonvalvular atrial fibrillation (AF), according to research presented by Faris Al-Khalili, MD, PhD, a cardiologist at the Karolinska Institute Danderyd Hospital in Stockholm. The observational study was conducted in more than 25,000 patients with nonvalvular AF at low risk of stroke.

"AF is the most common heart rhythm disturbance and is associated with a fivefold ncreased risk of ischemic stroke," said Dr. Al-Khalili. "AF is also associated with increased mortality, reduced quality of life, and a higher risk of heart failure."

Treatment with oral anticoagulants reduces the risk of stroke and is recommended according to the patient's number of stroke risk factors. Risk is estimated using the CHA2DS2-VASc score, which gives points for clinical risk factors. Patients with nonvalvular AF under age 65 who have a score of zero (in men) or one (in women) are considered to be at low risk for ischemic stroke, and oral anticoagulation therapy is not indicated for them.

"Even if the risk for stroke is low, it is not negligible, and a number of such low-risk patients do present with ischemic stroke in clinical practice and in patient registers," said Dr. Al-Khalili.  

The objective of this study was to assess the incidence and predictors of ischemic stroke among low-risk patients with nonvalvular AF. This retrospective study included 25,252 patients (ages 18 to 64) of a total of 34,523 patients with AF identified from the Swedish nationwide patient register for the period between January 1, 2006 and December 31, 2012. The median age was 55, and 72% of participants were men.

Information was available regarding  all hospitalizations and visits to hospital-affiliated open clinics in Sweden. Socioeconomic variables were obtained from a database for health insurance and labor market studies. Information about current medication was obtained from the National Drug Register, which has information about all dispensed prescription in Sweden and is 100% complete.

During a median follow-up of five years, ischemic stroke occurred at an annual rate of 3.4 per 1,000 patient-years. The overall mortality was 7.5 per 1,000 patient-years in patients without ischemic stroke and 29.6 per 1,000 patient-years in patients who had had an ischemic stroke during follow-up.

In the multivariable analysis, the only variables that remained significantly associated with an increased risk of ischemic stroke were age (hazard ratio [HR], 1.06) and alcohol-related hospitalization (HR, 2.01). Use of oral anticoagulants was associated with a lower risk of ischemic stroke (HR, 0.78).

"Even though these patients are classified as low-risk, the incidence of ischemic stroke in our study population is neither negligible nor ignorable, and it carries a relatively high mortality," said Dr. Al-Khalili.

"Previous studies have shown a causal and dose-response relation between alcohol and AF. Our study found that alcohol is an independent risk factor for stroke in patients with AF. Alcohol might induce AF, leading to embolic stroke, or there could be a specific alcohol effect that causes systemic or cerebral thromboembolism. Using alcohol-related hospitalization as a proxy for alcohol abuse likely underestimates the extent of the problem and does not allow grading of the amount of alcohol consumed.

"Doctors should ask their AF patients about alcohol use and advise patients to cut down if they are drinking more than is recommended. The beneficial link between oral anticoagulant use and ischemic stroke in this low-risk population without a recognized indication for these drugs needs further investigation, including the benefit to harm (bleeding) ratio," Dr. Al-Khalili concluded.

New Oral Anticoagulants Provide Same Stroke Prevention as Warfarin But Cause Less Bleeding
The new oral anticoagulants provide the same stroke prevention as warfarin, but cause less intracranial bleeding, according to research presented by Laila Staerk, PhD, a research fellow at Herlev and Gentofte University Hospital in Hellerup, Denmark.

"Atrial fibrillation is the most common cardiac rhythm disorder and currently affects more than 10 million Europeans," said Dr. Staerk. "Atrial fibrillation is associated with a fivefold risk of stroke, potentially leading to disability and death. In the next four decades, the number of patients with atrial fibrillation is expected to triple, so the number of Europeans diagnosed could rise to a staggering 25 to 30 million."

Patients with atrial fibrillation are treated life-long with oral anticoagulation to reduce their risk of stroke. But treatment with non-vitamin K antagonist oral anticoagulants (NOACs) and vitamin K antagonists (eg, warfarin) lowers the risk of stroke at the cost of increased bleeding risk.  

Several treatment options are available, and physicians may be unsure about which one to use. "There has been a need to investigate the safety and effectiveness of NOACs versus warfarin in a real-world population, and our Danish registries provide this opportunity," said Dr. Staerk.

The current study compared the risk of stroke and intracranial bleeding associated with NOACs (ie, dabigatran, rivaroxaban, and apixaban) versus that associated with warfarin in a real-world setting. The study was conducted at the Cardiovascular Research Centre at Herlev and Gentofte University Hospital. It included 43,299 patients with atrial fibrillation who were recruited from Danish nationwide administrative registries.

Approximately 42% of patients were taking warfarin, while 29%, 16%, and 13% were taking dabigatran, apixaban, and rivaroxaban, respectively. During follow-up, stroke occurred in 1,054 patients, and there were 261 intracranial bleedings.

The risk of having a stroke within one year was similar between the NOAC and warfarin groups and ranged from 2.0% to 2.5%. At one year, the risk of intracranial bleeding was significantly lower in patients treated with dabigatran and apixaban (0.3% to 0.4%), compared with that in those treated with warfarin (0.6%).

"The inclusion and exclusion criteria in our study were broadly similar for patients initiating NOACs or warfarin, and this gave a straightforward opportunity to directly compare the treatment regimens, which is in contrast to the randomized trials. The results suggest that although they have similar effects in preventing stroke, dabigatran and apixaban were associated with a safer use regarding the absolute one-year risk of intracranial bleeding," said Dr Staerk. "Our results complement the large randomized phase III trials by providing real-world data on stroke and intracranial bleeding with NOACs versus warfarin, since fragile patients were not excluded from our nationwide cohort. For example, patients with increased risk of bleeding, liver disease, and chronic kidney disease are less represented in trials."

"Registry studies have some limitations such as the observational design, residual confounding, and confounding by drug indication. In the future, it would be exciting to see a head-to-head randomized trial performed to compare the different NOAC treatments in patients with atrial fibrillation," said Dr Staerk.

Moderate Physical Activity Reduces Risk of Cardiovascular Death
Moderate physical activity is associated with a greater than 50% reduction in cardiovascular death in people older than 65, according to Riitta Antikainen, MD, Professor of Geriatrics at the University of Oulu in Finland. "These results prompt us to investigate the mechanisms through which the Mediterranean diet may protect against death," she said.

The 12-year study in nearly 2,500 adults between ages 65 and 74 found that moderate physical activity reduced the risk of an acute cardiovascular event by more than 30%. High levels of physical activity led to greater risk reductions.

"The role of physical activity in preventing cardiovascular disease [CVD] in people of working age is well established," said Dr. Antikainen. "But relatively little is known about the effect of regular physical activity on CVD risk in older people."

The present study assessed the association between leisure time physical activity and CVD risk and mortality in 2,456 men and women who were enrolled into the National FINRISK Study between 1997 and 2007.

Baseline data collection included self-administered questionnaires on physical activity and other health related behavior, clinical measurements (eg, blood pressure, weight, and height), and laboratory measurements, including serum cholesterol. Participants were followed up until the end of 2013. Deaths were recorded from the National Causes of Death Register, and incident CVD events (ie, coronary heart disease and stroke) were collected from the National Hospital Discharge register.

The researchers classified self-reported physical activity as low, moderate, or high. Low physical activity included reading, watching TV, and working in the household without much physical activity. Moderate physical activity encompassed walking, cycling, or practicing other forms of light exercise (eg, fishing, gardening, hunting) for at least four hours per week. High physical activity included recreational sports (eg, running, jogging, skiing, gymnastics, swimming, or ball games) or intense training or sports competitions for at least three hours per week.  

During a median follow-up of 11.8 years, 197 participants died from CVD, and 416 had a first CVD event.

When the researchers assessed the link between physical activity and outcome, they adjusted for other cardiovascular risk factors (ie, blood pressure, smoking, and cholesterol) and social factors (ie, marital status and education). To minimize reverse causality, where worse health leads to less physical activity, patients with coronary heart disease, heart failure, cancer, or prior stroke at baseline were excluded from the analysis.

The investigators found that moderate and high leisure-time physical activity were associated with a 31% and 45% reduced risk of an acute CVD event, respectively. Moderate and high leisure-time physical activity were associated with a 54% and 66% reduction in CVD mortality, respectively.

"Our study provides further evidence that older adults who are physically active have a lower risk of coronary heart disease, stroke, and death from cardiovascular disease. The protective effect of leisure time physical activity is dose dependent. In other words, the more you do, the better. Activity is protective even if you have other risk factors for cardiovascular disease such as high cholesterol," said Dr. Antikainen.  

"Physical exercise may become more challenging with aging. However, it is important for older people to still get enough safe physical activity to stay healthy after their transition to retirement."         

Low Socioeconomic Status Associated With Higher Risk of Second Heart Attack or Stroke
Low socioeconomic status is associated with a higher risk of a second heart attack or stroke, according to Joel Ohm, MD, a physician at the Karolinska University Hospital and Karolinska Institute in Stockholm. The study of nearly 30,000 patients with a prior heart attack revealed that the risk of a second event was 36% lower for those in the highest income quintile, compared with the lowest, and increased by 14% in divorced patients, compared with married patients.

"Are you rich or poor? Married or divorced? That might affect your risk of a second heart attack or stroke," said Dr. Ohm. "Advances in prevention and acute treatment have increased survival after heart attack and stroke over the past several decades. The result is that more people live with cardiovascular disease in Sweden. Almost one-fifth of the total population is in this group."

Most research on cardiovascular prevention is based on healthy people, and it is unclear whether the findings apply to patients with established disease. An association between socioeconomic status in healthy individuals and future cardiovascular disease was found in the 1950s. This study investigated the link between socioeconomic status in patients who had survived a first heart attack and the risk of a second heart attack or a stroke.

The study included 29,953 patients from the Swedish nationwide registry, Secondary Prevention after Heart Intensive Care Admission (SEPHIA), who had been discharged approximately one year previously from a cardiac intensive care unit after treatment for a first myocardial infarction. Data on outcome over time and socioeconomic status (defined as disposable income, marital status, and level of education) was obtained from Statistics Sweden and the National Board of Health and Welfare.

During an average follow-up of four years, 2,405 patients (8%) had a heart attack or stroke. After adjustments for age, gender, smoking status, and the defined measures of socioeconomic status, being divorced was independently associated with a 14% greater risk of a second event, compared with being married. There was an independent and linear relationship between disposable income and the risk of a second event, with those in the highest quintile of income having a 36% lower risk than those in the lowest quintile. A higher level of education was associated with a lower risk of events, but the association was not significant after adjustment for income.

"Our study shows that in the years following a first myocardial infarction, men and women with low socioeconomic status have a higher risk of suffering another heart attack or stroke. This is a new finding and suggests that socioeconomic status should be included in risk assessment for secondary prevention after a heart attack," said Dr Ohm. "Even though health care providers are unlikely to keep track of their patients' yearly salary, simple questions about other socioeconomic variables such as marital status and educational level could make a difference."

According to the widely used assessment tools for cardiovascular risk, survivors of heart attacks are at the highest possible risk for subsequent events, regardless of other risk factors. There is, for example, no difference in the estimated risk level between a previously healthy 40-year old female from Spain and a heavily smoking, obese, elderly man with diabetes and high blood pressure from Finland.

"Risk assessment tools are designed for individuals without previous cardiovascular disease, and the calculations may not apply to patients with established cardiovascular disease. Socioeconomic status is perhaps a better marker to assess risk of future events in heart attack patients, and more research is needed to determine other factors that could be included, such as occupation or residential area," said Dr Ohm.

Alcohol-Related Hospitalization Associated With Doubled Stroke Risk in Atrial Fibrillation
Alcohol-related hospitalization is associated with a doubled risk of ischemic stroke in patients with nonvalvular atrial fibrillation (AF), according to research presented by Faris Al-Khalili, MD, PhD, a cardiologist at the Karolinska Institute Danderyd Hospital in Stockholm. The observational study was conducted in more than 25,000 patients with nonvalvular AF at low risk of stroke.

"AF is the most common heart rhythm disturbance and is associated with a fivefold ncreased risk of ischemic stroke," said Dr. Al-Khalili. "AF is also associated with increased mortality, reduced quality of life, and a higher risk of heart failure."

Treatment with oral anticoagulants reduces the risk of stroke and is recommended according to the patient's number of stroke risk factors. Risk is estimated using the CHA2DS2-VASc score, which gives points for clinical risk factors. Patients with nonvalvular AF under age 65 who have a score of zero (in men) or one (in women) are considered to be at low risk for ischemic stroke, and oral anticoagulation therapy is not indicated for them.

"Even if the risk for stroke is low, it is not negligible, and a number of such low-risk patients do present with ischemic stroke in clinical practice and in patient registers," said Dr. Al-Khalili.  

The objective of this study was to assess the incidence and predictors of ischemic stroke among low-risk patients with nonvalvular AF. This retrospective study included 25,252 patients (ages 18 to 64) of a total of 34,523 patients with AF identified from the Swedish nationwide patient register for the period between January 1, 2006 and December 31, 2012. The median age was 55, and 72% of participants were men.

Information was available regarding  all hospitalizations and visits to hospital-affiliated open clinics in Sweden. Socioeconomic variables were obtained from a database for health insurance and labor market studies. Information about current medication was obtained from the National Drug Register, which has information about all dispensed prescription in Sweden and is 100% complete.

During a median follow-up of five years, ischemic stroke occurred at an annual rate of 3.4 per 1,000 patient-years. The overall mortality was 7.5 per 1,000 patient-years in patients without ischemic stroke and 29.6 per 1,000 patient-years in patients who had had an ischemic stroke during follow-up.

In the multivariable analysis, the only variables that remained significantly associated with an increased risk of ischemic stroke were age (hazard ratio [HR], 1.06) and alcohol-related hospitalization (HR, 2.01). Use of oral anticoagulants was associated with a lower risk of ischemic stroke (HR, 0.78).

"Even though these patients are classified as low-risk, the incidence of ischemic stroke in our study population is neither negligible nor ignorable, and it carries a relatively high mortality," said Dr. Al-Khalili.

"Previous studies have shown a causal and dose-response relation between alcohol and AF. Our study found that alcohol is an independent risk factor for stroke in patients with AF. Alcohol might induce AF, leading to embolic stroke, or there could be a specific alcohol effect that causes systemic or cerebral thromboembolism. Using alcohol-related hospitalization as a proxy for alcohol abuse likely underestimates the extent of the problem and does not allow grading of the amount of alcohol consumed.

"Doctors should ask their AF patients about alcohol use and advise patients to cut down if they are drinking more than is recommended. The beneficial link between oral anticoagulant use and ischemic stroke in this low-risk population without a recognized indication for these drugs needs further investigation, including the benefit to harm (bleeding) ratio," Dr. Al-Khalili concluded.

New Oral Anticoagulants Provide Same Stroke Prevention as Warfarin But Cause Less Bleeding
The new oral anticoagulants provide the same stroke prevention as warfarin, but cause less intracranial bleeding, according to research presented by Laila Staerk, PhD, a research fellow at Herlev and Gentofte University Hospital in Hellerup, Denmark.

"Atrial fibrillation is the most common cardiac rhythm disorder and currently affects more than 10 million Europeans," said Dr. Staerk. "Atrial fibrillation is associated with a fivefold risk of stroke, potentially leading to disability and death. In the next four decades, the number of patients with atrial fibrillation is expected to triple, so the number of Europeans diagnosed could rise to a staggering 25 to 30 million."

Patients with atrial fibrillation are treated life-long with oral anticoagulation to reduce their risk of stroke. But treatment with non-vitamin K antagonist oral anticoagulants (NOACs) and vitamin K antagonists (eg, warfarin) lowers the risk of stroke at the cost of increased bleeding risk.  

Several treatment options are available, and physicians may be unsure about which one to use. "There has been a need to investigate the safety and effectiveness of NOACs versus warfarin in a real-world population, and our Danish registries provide this opportunity," said Dr. Staerk.

The current study compared the risk of stroke and intracranial bleeding associated with NOACs (ie, dabigatran, rivaroxaban, and apixaban) versus that associated with warfarin in a real-world setting. The study was conducted at the Cardiovascular Research Centre at Herlev and Gentofte University Hospital. It included 43,299 patients with atrial fibrillation who were recruited from Danish nationwide administrative registries.

Approximately 42% of patients were taking warfarin, while 29%, 16%, and 13% were taking dabigatran, apixaban, and rivaroxaban, respectively. During follow-up, stroke occurred in 1,054 patients, and there were 261 intracranial bleedings.

The risk of having a stroke within one year was similar between the NOAC and warfarin groups and ranged from 2.0% to 2.5%. At one year, the risk of intracranial bleeding was significantly lower in patients treated with dabigatran and apixaban (0.3% to 0.4%), compared with that in those treated with warfarin (0.6%).

"The inclusion and exclusion criteria in our study were broadly similar for patients initiating NOACs or warfarin, and this gave a straightforward opportunity to directly compare the treatment regimens, which is in contrast to the randomized trials. The results suggest that although they have similar effects in preventing stroke, dabigatran and apixaban were associated with a safer use regarding the absolute one-year risk of intracranial bleeding," said Dr Staerk. "Our results complement the large randomized phase III trials by providing real-world data on stroke and intracranial bleeding with NOACs versus warfarin, since fragile patients were not excluded from our nationwide cohort. For example, patients with increased risk of bleeding, liver disease, and chronic kidney disease are less represented in trials."

"Registry studies have some limitations such as the observational design, residual confounding, and confounding by drug indication. In the future, it would be exciting to see a head-to-head randomized trial performed to compare the different NOAC treatments in patients with atrial fibrillation," said Dr Staerk.

Moderate Physical Activity Reduces Risk of Cardiovascular Death
Moderate physical activity is associated with a greater than 50% reduction in cardiovascular death in people older than 65, according to Riitta Antikainen, MD, Professor of Geriatrics at the University of Oulu in Finland. "These results prompt us to investigate the mechanisms through which the Mediterranean diet may protect against death," she said.

The 12-year study in nearly 2,500 adults between ages 65 and 74 found that moderate physical activity reduced the risk of an acute cardiovascular event by more than 30%. High levels of physical activity led to greater risk reductions.

"The role of physical activity in preventing cardiovascular disease [CVD] in people of working age is well established," said Dr. Antikainen. "But relatively little is known about the effect of regular physical activity on CVD risk in older people."

The present study assessed the association between leisure time physical activity and CVD risk and mortality in 2,456 men and women who were enrolled into the National FINRISK Study between 1997 and 2007.

Baseline data collection included self-administered questionnaires on physical activity and other health related behavior, clinical measurements (eg, blood pressure, weight, and height), and laboratory measurements, including serum cholesterol. Participants were followed up until the end of 2013. Deaths were recorded from the National Causes of Death Register, and incident CVD events (ie, coronary heart disease and stroke) were collected from the National Hospital Discharge register.

The researchers classified self-reported physical activity as low, moderate, or high. Low physical activity included reading, watching TV, and working in the household without much physical activity. Moderate physical activity encompassed walking, cycling, or practicing other forms of light exercise (eg, fishing, gardening, hunting) for at least four hours per week. High physical activity included recreational sports (eg, running, jogging, skiing, gymnastics, swimming, or ball games) or intense training or sports competitions for at least three hours per week.  

During a median follow-up of 11.8 years, 197 participants died from CVD, and 416 had a first CVD event.

When the researchers assessed the link between physical activity and outcome, they adjusted for other cardiovascular risk factors (ie, blood pressure, smoking, and cholesterol) and social factors (ie, marital status and education). To minimize reverse causality, where worse health leads to less physical activity, patients with coronary heart disease, heart failure, cancer, or prior stroke at baseline were excluded from the analysis.

The investigators found that moderate and high leisure-time physical activity were associated with a 31% and 45% reduced risk of an acute CVD event, respectively. Moderate and high leisure-time physical activity were associated with a 54% and 66% reduction in CVD mortality, respectively.

"Our study provides further evidence that older adults who are physically active have a lower risk of coronary heart disease, stroke, and death from cardiovascular disease. The protective effect of leisure time physical activity is dose dependent. In other words, the more you do, the better. Activity is protective even if you have other risk factors for cardiovascular disease such as high cholesterol," said Dr. Antikainen.  

"Physical exercise may become more challenging with aging. However, it is important for older people to still get enough safe physical activity to stay healthy after their transition to retirement."