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PURE: Just 150 Minutes of Physical Activity Weekly Reduces CV Disease, Deaths

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New findings from the PURE study group reaffirm the value of physical activity to reduce death and cardiovascular disease and extend this finding to persons living in low- and middle-income countries and to all types of physical activity. The prospective cohort study found that 30 minutes of physical activity five days a week could prevent one in 12 deaths and one in 20 cases of cardiovascular disease worldwide. A greater reduction was seen in those who were highly active (750 minutes weekly).

In the study, 130,843 participants aged 35-70 years old from urban and rural areas in 17 countries (four low-income and seven middle-income) completed questionnaires on their levels and types of physical activity over a typical week. Information was also obtained on socioeconomic status, lifestyle behaviors, medical history, family history of cardiovascular disease, weight, height, waist and hip measurements, and blood pressure. Follow-up visits were completed every three years over the 6.9 years of follow-up. Read More >>>

It is estimated that about 23 percent of adults aged 18-64 years worldwide do not meet the levels of physical activity recommended by the World Health Organization: at least 150 minutes of moderate-intensity aerobic physical activity throughout the week, and muscle strengthening exercise at least two days a week. In the PURE study, 18 percent of participants did not meet the physical activity guidelines, while 44 percent were highly active.

The results, published in The Lancet, showed that among the participants who met the activity guidelines, compared with those who did not, there was a lower rate of developing cardiovascular disease (3.8 percent vs. 5.1 percent) and risk of mortality (4.2 percent vs. 6.4 percent).

In translating these results to a population level, the authors, led by Scott A. Lear, PhD, state the findings suggest 8 percent of deaths and 4.6 percent of cardiovascular disease cases could be prevented. These levels could be increased to 13 percent and 9.5 percent if the entire population was highly active.

Physical activity as transport, occupation or housework was the most common form of physical activity, across all regions (ranging from 437 to 574 minutes per week). While physical activity in leisure time was common in high-income countries (average of 130 minutes per week), it was rare in other regions (25 minutes a week in lower-middle income countries and none in upper-middle- and low-income countries).

“As participating in physical activity (especially in daily life) is inexpensive, physical activity is a low-cost approach to reducing deaths and [cardiovascular disease] CVD that is applicable globally with large potential effect,” the authors write. They add their study provides robust evidence to support public health interventions to increase all forms of physical activity in these regions.

In a related editorial, Shifalika Goenka, MBBS, PhD, writes, “Cardiovascular disease is known to have devastating effects on individuals and families. In low-income and lower-middle-income countries, cardiovascular disease can push people to below the poverty line… Creating a physical, social, and political environment where physical activity in daily living is desirable, accessible, and safe should be a developmental imperative… Promotion of physical activity, active transport, and active living by means of interventions contextualised to culture and context will have powerful and long-lasting effects on population health and developmental sustainability.”


Lear SA, Hu W, Rangarajan S, et al. Lancet 2017;Sept 21:[Epub ahead of print].

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Low-Dose Aspirin Discontinuation Linked to Higher Cardiovascular Risk

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Among long-term users, discontinuation of low-dose aspirin in the absence of major surgery or bleeding was associated with more than a 30 percent increased risk of cardiovascular events, according to a study published in Circulation.

In a large nationwide patient cohort study, Johan Sundström, MD, PhD, et al., assessed 601,527 users of low-dose aspirin for primary or secondary prevention in the Swedish prescription register between 2005 and 2009. Users were over 40 years old, free from previous cancer and had 80 percent or more adherence during the first observed year of treatment. The first three months after a major bleeding or surgical procedure were excluded from the time at risk. Read More >>>

During a median follow-up of three years, results showed that 62,690 cardiovascular events occurred. Patients who discontinued aspirin had a higher rate of cardiovascular events than those who continued (multivariable-adjusted hazard ratio, 1.37) – consistent with an additional cardiovascular event observed per year in one of every 74 patients who discontinue aspirin. The risk appeared to increase as soon as patients discontinued aspirin, with no safe interval.

Subgroup analyses showed patients who were older and had prior cardiovascular disease were at higher risk for cardiovascular events when off aspirin, whereas treatment with oral anticoagulant or other antiplatelet drugs was associated with lower risk increase for cardiovascular events when off aspirin.

Aspirin discontinuation was found to be particularly dangerous among patients with previous cardiovascular disease. An additional cardiovascular event per year occurred in every one of 36 secondary prevention patients who discontinued aspirin compared with an additional cardiovascular event per year in every one of 146 primary prevention patients who discontinued aspirin.

“Strengths include the large contemporary sample rendering >60,000 cardiovascular events, universal coverage of the prescription register and hence inclusion of all long-term low-dose aspirin users nationwide, the universal coverage of the high-precision registers for determining the outcomes, and minimal loss to follow-up,” the study authors write.


Sundström J, Hedberg J, Thuresson M, et al. Circulation 2017; 136:1183-92.

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Higher Long-Term Risk of Death in STE-ACS Patients Without Obstructive CAD

Patients with ST-elevation acute coronary syndrome (STE-ACS) without obstructive coronary artery disease (CAD) have a lower short-term risk of death. But, their long-term risk of death is similar with or higher than patients with obstructive CAD, according to a study recently published in the European Heart Journal.

Hedvig Bille Andersson, MD, et al., examined short- and long-term survival and causes of death in patients with STE-ACS without obstructive CAD compared with patients with STE-ACS with obstructive CAD and with the general population. All patients with STE-ACS scheduled for acute coronary angiography between November 2009 and December 2014 at Copenhagen University Hospital were identified from the Eastern Danish Heart Registry. Read More >>>

A total of 4,793 patients were included, 6 percent with non-obstructive CAD, 88 percent with obstructive CAD and 5 percent with normal coronary arteries. The median follow-up was 2.6 years. The estimated risk of death within 30 days was 7 percent for patients with obstructive CAD, 4 percent for patients with non-obstructive CAD (hazard ratio [HR], 0.49; p = 0.018 vs. obstructive CAD) and 2 percent for those with normal coronary arteries (HR, 0.31; p = 0.021 vs. obstructive CAD).

According to a 30-day landmark analysis, the long-term risk of death was similar in patients with non-obstructive and obstructive CAD. Patients with normal arteries had an increased long-term risk of death compared with patients with obstructive CAD (HR, 2.44; p < 0.001).

Compared with the general population, the 30-day risk of death was higher for all three groups (p < 0.001), while the long-term risk of death was similar for obstructive CAD (HR, 1.1; p = 0.076) but higher for non-obstructive CAD (HR, 1.55; p = 0.024) and normal arteries (HR, 2.6; p ≤ 0.001).

The cause of death within 30 days was cardiovascular in 92 percent of patients with obstructive CAD, 75 percent of patients with non-obstructive CAD and 50 percent with normal arteries. The long-term cause of death was cardiovascular in 50 percent of patients with obstructive CAD, 21 percent with non-obstructive CAD and 29 percent with normal arteries.

The authors note that approximately one in nine patients triaged for coronary angiography for STE-ACS did not have obstructive disease in what they believe is the largest study assessing long-term survival and causes of death in STE-ACS patients with and without obstructive disease. These results “suggest that STE-ACS patients without obstructive CAD might benefit from increased medical attention, secondary prevention interventions, and close follow-up,” conclude the authors.


Andersson HB, Pedersen F, Engstrøm T, et al. Eur Heart J 2017;Sept 23:[Epub ahead of print].

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Income, Not Food Desert, Major Driver of Higher Cardiovascular Risk

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Individual income status, hence capacity to afford healthy food, and area income are the major drivers of the higher risk of cardiovascular disease seen in people living in food deserts, according to a study published in Circulation: Cardiovascular Quality and Outcomes.

Using data from 1,421 participants from both the META-Health and the Predictive Health studies conducted in metropolitan Atlanta, GA, Heval M. Kelli, MD, et al., examined the impact of living in food deserts, neighborhoods defined as low income with less access to healthy food. Investigators examined demographic data, metabolic profiles, high-sensitivity C-reactive protein (hs-CRP) levels, oxidative stress markers and arterial stiffness. Mean age was 49.4 years, 38.5 percent were men and 36.6 percent were black. Annual household income in 11.2 percent was less than $25,000, and 47.9 percent had an income less than $75,000. Read More >>>

Results showed that participants living in food deserts (n = 187; 13.2 percent), compared with those who did not, more often were black (52 percent vs. 34 percent) with less college education and lower income levels. Their cardiovascular risk profile was more unfavorable, with a higher prevalence of hypertension and smoking, higher levels of body mass index and fasting glucose, and a higher atherosclerotic cardiovascular disease score (p = 0.007).

Systemic oxidative stress, inflammation and arterial stiffness were also found to be increased in participants living in food deserts. In a multivariate analysis including food access, area income and individual income, both low-income area and low individual household income were independent predictors of a higher 10-year risk for cardiovascular disease. Only low individual income was an independent predictor of higher hs-CRP and augmentation index.

“The present study is the first to report the relationship between living in a food desert, cardiovascular risk factors and subclinical vascular disease,” the authors write. “This understanding may help to better tailor resources to affected communities and improve utilization of public health resources.”


Kelli HM, Hammadah M, Ahmed H, et al. Circ Cardiovasc Qual Outcomes 2017;Sept 13:[Epub ahead of print].

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Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Diabetes and Cardiometabolic Disease, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, ACS and Cardiac Biomarkers, Anticoagulation Management and ACS, Lipid Metabolism, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Nuclear Imaging, Diet, Exercise, Hypertension, Smoking, Stress

Keywords: ACC Publications, Cardiology Magazine, Acute Coronary Syndrome, Adult, Anticoagulants, Aspirin, Biological Transport, Active, Blood Pressure, Body Mass Index, Cardiovascular Diseases, Cause of Death, Coronary Angiography, Coronary Artery Disease, C-Reactive Protein, Developed Countries, Exercise, Fasting, Follow-Up Studies, Glucose, Health Resources, Hospitals, University, Hypertension, Income, Inflammation, Leisure Activities, Life Style, Metabolome, Multivariate Analysis, Neoplasms, Occupations, Oxidative Stress, Plant Oils, Plant Oils, Platelet Aggregation Inhibitors, Poverty, Prevalence, Primary Prevention, Prospective Studies, Public Health, Registries, Research Personnel, Risk Factors, Secondary Prevention, Smoking, Social Class, Universal Coverage, Vascular Stiffness


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