a Cardiology Department, Bichat Hospital, AP-HP, Paris, France
b Epidemiology, Biostatistic, and Clinical Research Department, Bichat Hospital, AP-HP, Paris, France
c Cardiac Surgery Department, University Hospital, Wales, Cardiff, UK
d Cardiology Department, Hopital Cardiologique, Lyon, France
e Cardiology Department, Heart Centre, Bad Krozingen, Germany
f Cardiac Surgery Department, St. Elizabeth Hospital, Trondheim, Norway
g Cardiology Department, Vall dHebron Hospital, Barcelona, Spain
h Division of Cardiology, Catholic University of Louvain, Brussels, Belgium
i Laurentius Ziekenhuis Roermond, Netherlands
j Thoraxcentre, Rotterdam, Netherlands
* Corresponding author: Bernard Iung, MD, Cardiology Department, Bichat Hospital, 46 rue Henri Huchard, 75018 Paris, France. Tel.: +33-1-40-25-67-60; fax. +33-1-40-25-67-32
E-mail address: bernard.iung{at}bch.ap-hop-paris.fr
Received 9 January 2003; revised 7 March 2003; accepted 12 March 2003
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Abstract |
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Methods and results The Euro Heart Survey on VHD was conducted from April to July 2001 in 92 centres from 25 countries; it included prospectively 5001 adults with moderate to severe native VHD, infective endocarditis, or previous valve intervention. VHD was native in 71.9% of patients and 28.1% had had a previous intervention. Mean age was 64±14 years. Degenerative aetiologies were the most frequent in aortic VHD and mitral regurgitation while most cases of mitral stenosis were of rheumatic origin.
Coronary angiography was used in 85.2% of patients before intervention. Of the 1269 patients who underwent intervention, prosthetic replacement was performed in 99.0% of aortic VHD, percutaneous dilatation in 33.9% of mitral stenosis, and valve repair in 46.5% of mitral regurgitation; 31.7% of patients had 1 associated procedure. Of patients with severe, symptomatic, single VHD, 31.8% did not undergo intervention, most frequently because of comorbidities. In asymptomatic patients, accordance with guidelines ranged between 66.0 and 78.5%. Operative mortality was <5% for single VHD.
Conclusions This survey provides unique contemporary data on characteristics and management of patients with VHD. Adherence to guidelines is globally satisfying as regards investigations and interventions.
Key Words: Valvular heart disease Echocardiography Cardiac surgery
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1. Introduction |
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Although valvular heart disease (VHD) is less frequent than coronary disease, heart failure, or hypertension, it is of interest for several reasons: firstly, VHD is still common and often requires intervention. Secondly, important changes have occurred as regards the presentation and treatment of the disease over recent years, and thirdly there are very few registers or trials in the field as compared with other heart diseases. In addition, no such survey exists in the field of VHD.
The same limitations exist with regard to guidelines. There is only one set of guidelines in the field of VHD in the USA4and three national guidelines in Europe.57Moreover, recent publications suggest that there is a real gap between the existing guidelines and their effective application.810
Thus there is a need for contemporary information on VHD in Europe, and this was the purpose of this survey.
As was the case for other surveys in the EHS programme, the aims of EHS on VHD were to characterise frequency and outcomes of valve disease in Europe, to evaluate current practices in the management of the disease, and finally to compare them whenever possible with available guidelines.
We present herein the initial assessment and the 30-day results concentrating on patients characteristics, diagnostic procedures, and interventions.
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2. Methods |
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2.2. Duration of Survey
The survey was designed to include all consecutive consenting patients between 1st April to 31 July 2001 who meet the inclusion criteria. Follow-up was to be made either personally or by telephone by the local investigator at 30 days. One-year follow-up is ongoing.
2.3. Patients
The screened population consisted of patients who were hospitalised in medical or surgical cardiology departments, and those who were seen in outpatient clinics (1 day per week, the day being chosen randomly each week) of medical departments included in the clusters.
The case report form was filled out only for patients fulfilling the inclusion criteria which were as follows.
The inclusion was performed by the cluster Data Collection Officer. The case report form included details regarding the demographic, clinical, and echocardiographic characteristics of the patient. For hospitalized patients, the case report form comprised also details on diagnostic and treatment modalities, in-hospital complications, and discharge status. In addition, the Data Collection Officer was asked to interview the attending physicians for decisions regarding the main reasons for the choice of management and therapy. The case report form contained 809 variables. Aetiologies of VHD were classified following surgical findings if applicable, echocardiographic findings, and clinical context. Severe VHD was defined as AS with a valve area 0.6cm2/m2body surface area, MS with a valve area
1.5 cm2, AR grade
3/4, or MR grade
3/4.11
2.4. Data Collection
In each hospital, data were collected using the MacroTM software (InferMed, UK) on portable computers and sent to the central database in the European Heart House via the Internet. Initial internal edit checks for missing or contradictory entries or for values excessively out of the normal range were implemented by the software. Additional edit checks were implemented by the data management staff at the European Heart House and the EHS VHD data analysis centre at Bichat Hospital. Patient identification was not entered on the local computer or transferred to the central database.
Site audits for source document verification versus data collected in the central database, were randomly performed by the EHS staff in sample sites. Site audits were not intended to validate the accuracy of the discharge diagnosis by the attending physicians.
Analysis was performed with SAS statistical software (SAS Institute Inc, release 8.2). Results are presented as mean±standard deviation orpercentages.
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3. Results |
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The sites of inclusion were medical departments in 2128 patients (42.5%), out-patient clinics in 1934 (38.7%), and surgical departments in 939 (18.8%). The reasons for inclusion are summarised in Table 1. Of the 5001 patients, 1269 underwent a valvular intervention during the survey period.
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Stress tests were performed in 7.9% of the total and 7.4% of the operated patients. It was exercise electrocardiography in 70.0% of cases. The reasons for performing the tests were: assessment of functional capacity in patients with no or equivocal symptoms (49.1%), before allowing the performance of strenuous exercise (13.1%), for prognosis evaluation in presence of left ventricular dysfunction (12.1%), to detect coronary disease (61.0%), and systematic (22.9%, as a sole reason in 1.0%). In severe AS an exercise test was performed in only 5.7% of patients with no symptoms. On the other hand it was still performed in 3.2% of patients in NYHA class III or IV.
Catheterization was performed in 31.1% of the total population and 63.0% among the operated patients. In the global population, the type of catheterization were: isolated right heart catheterization in 2.8% of the cases, left heartcatheterization in 11.6%, and right and left heart catheterization in 16.7%. The most frequent indications were: to assess severity of valve lesion (50.6%) or left ventricular function (23.3%) in case of inconclusive non-invasive testing. Catheterization was said to be systematically combined with coronary angiography in 62.9% of cases and this was the sole reason for performance in 29.1%.
Coronary angiography was the most frequently performed investigation: 43.0% of cases in total and 84.9% in operated patients. In the global population, it showed the presence of coronary artery disease in 39.4% of cases: 1-vessel disease in 13.9%, 2-vessel disease in 11.5%, 3-vessel disease in 12.8%, and left main disease in 1.2%. The reasons for performing coronary angiography in the global population were: presence of 1 risk factor before surgery (72.1%), suspicion of ischaemia (32.9%), presence of ischaemia in a patient with moderate valve lesion (24.3%), ischaemia suspected as an aetiology (16.6%). Finally coronary angiography was claimed to be systematically combined with catheterization in 44.7% (as the sole reason in 7.6%).
Among the 188 patients (14.8%) who did not undergo coronary angiography before surgery, the reasons advocated for not performing the investigation were: absence of cardio vascular risk factor (31.3%), acute endocarditis (14.9%), aortic dissection (2.7%), emergency operation (11.7%), poor haemodynamic condition (14.4%), no catheterization facility available (2.1%), and the absence of evidence of ischaemia (72.8%) (as the sole reason in 31.3%, i.e. in 4.6% of all patients who underwent intervention).
3.3. Interventions performed
3.3.1. Population
An intervention was planned in 1740 patients during the survey period. In 471 patients (27.1%) intervention was scheduled but not yet performed during the study period, 85.6% of them were on a waiting list with a mean duration of 8±4 weeks, up to 24 weeks.
The other 1269 patients underwent intervention during the survey. Interventions were performed on an elective basis in 73.0% of patients, urgently in 25.0% (performed during the same hospital stay), and as an emergency in 2.0% (within 24 h after admission).
As shown in Table 2, interventions were performed for native VHD in 87.0% of patients, mostly for AS, and were re-do operations in 13.0%.
The demographics of the patients who underwent an intervention are comparable to the total population: their mean age was 64±13 years [range: 2092], 16.1% were aged <50 years, 46.4% between 50 and 70, 32.1% between 70 and 80, and 5.4% 80 (0.1% being
90); 46.7% were females. The distribution of preoperative symptoms was as follows: 13.9% in NYHA class I, 29.5% in class II, 43.1% in class III, and 13.5% in class IV. Congestive heart failure was present at the time of intervention in 21.3% of the patients. The detailed preoperative characteristics of the largest groups of patients are given in Table 6.
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The comparison between the reasons given for intervention in asymptomatic patients (NYHA class I and no angina) with severe single valve disease and the recent recommendations is shown in Fig. 1.11The actual management was in accordance with these recommendations in 66.0 to 78.5% of cases among the different single native valve disease. The feasibility of repair was considered as a factor in 23.3% of cases, in particular in mitral valve disease where it was mentioned in 48.4% of cases.
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3.3.4. Reasons for the choice of the type of intervention
The reasons for choosing valve replacement over valve repair in patients with MR were: unfavourable anatomy (77.1%), or failure of conservative surgery (10.2%). Valve replacement was also the only option in the absence of local availability of conservative surgery (32.5%). Finally cardiologists or surgeons preference (40.9%, 4.8% as the sole reason) was more frequently a factor than patients preference (7.7%).
Another question concerned the choice of the type of prosthesis to implant in patients with AS. The reasons for choosing a mechanical prosthesis were: young age (84.6%), a mechanical valve in another position (1.6%), renal failure (0.8%), anticoagulation for other purpose (7.3%), physicians or surgeons preference (70.5%, 4.9% as the sole reason), or patients preference (19.0%). In patients operated on for AS, the distribution between mechanical prosthesis and bioprosthesis according to age is shown in Fig. 2.
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4. Discussion |
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4.1. Patient characteristics
As regards the distribution of VHD, AS was the most frequent native valve disease followed by MR, while AR and MS were observed with equivalent frequency. In this survey, patients with previous valve interventions represented a significant sub-group for which we unfortunately have very little data available and very few guidelines.
Rheumatic disease used to be the most frequent etiology of valve disease in previous decades, but this survey, like other contemporary series from Europe and the USA,1518shows that degenerative origin is by far the most frequent in AS, MR, and AR, with the associated implications related to patient characteristics and treatment. Endocarditis is still a serious concern in AR and MR. Finally an ischemic origin is present in 7.3% of MR.
Overall the patients with VHD are often elderly with a high frequency of cardiovascular risk factors and comorbidities.19These changes in aetiology and clinical characteristics have important implications for management.
4.2. Investigations
Besides transthoracic echocardiography, which was required for inclusion in the survey, the work-up of patients participating in the survey included few other non-invasive investigations. The reasons given for the use of transoesophageal echocardiography in the survey were in good agreement with the current recommendations,20,21even if the overall use of the technique was rather low.
The use of stress testing was low and essentially aimed at identifying coronary artery disease, which it does poorly in the setting of valve disease. Exercise testing is too seldom used in asymptomatic patients with valve disease. This is particularly true for AS, despite the fact that the performance of the test is strongly advocated in the recent European recommendations and is a grade IIa recommendation in the ACC/AHA guidelines.4,11,22This under-use may be explained by an insufficientimplementation of the current guidelines and fear of complications or inexperience in exercise testing.
Catheterisation was the second most frequently performed investigation. In most of the cases it was performed to assess the severity of valve lesions, however in as much as 28.7% of the cases it was performed in a systematic fashion in combination with coronary angiography. This high figure is surprising at a time when there is a large amount of data showing the accuracy of echocardiography in assessing the severity of valve disease. The performance of catheterization in the absence of discordant clinical findings and echocardiography is either grade IIb or grade III according to the type of valve disease.4This over-use may be due to the fact that clinicians want further reassurance before advising operation. However the over-use of catheterization is not without risks, in particular in AS, and increases costs.23
As expected, because of the characteristics of the patients in the survey, coronary angiography was the most frequently performed investigation. This was particularly true in patients undergoing surgery. In this setting, the reasons for performing or not performing the investigation were sought. Overall the agreement between practice andguidelines was good.4
4.3. Interventions performed
The demographics of the patients operated on in this survey are similar to those of other series, for example in severe AS over half of the patients were operated on after the age of 70 years.24,25In keeping with the patient characteristics and the predominance of degenerative aetiologies, intervention is often necessary in elderly patients with coronary disease and comordidities.12In addition intervention is a re-do operation in more than 10% of the cases. Besides these characteristics which increase the operative risk, another important finding is that intervention is often performed at an early stage of the disease, since almost half of the patients were in NYHA Class I or II at the time of operation, with 13.9% being operated on at an asymptomatic stage. This trend towards early intervention is confirmed by the fact that the majority of patients with AS and AR and even more importantly MR are operated on with preserved left ventricular function. The overall correspondence between the recent recommendations and the practice in 66 to 78.5% of cases in the survey is encouraging in this respect.11The feasibility of valve repair has been often considered as an incentive for early intervention in particular in mitral valve disease where conservative surgery and percutaneous intervention are available. These encouraging findings should not, however, lead us to forget that a tenth of the patients are still being operated on at a far too advanced stage of the disease.
The reasons for not advising intervention in patients with severe valve disease were either cardiac, extracardiac, or both.
Among the cardiac reasons, as in another study, decrease of symptoms under medical treatment is often wrongly cited as justification for procrastination.9The other reasons are debatable and more controversial. For example, severe depression of left ventricular function should seldom be used as a contraindication even if it increases the operative risk. Recent myocardial infarction may delay surgery but will not contraindicate it in most cases. Finally, severe coronary disease is seldom not by-passable unless diffuse and distal. As a general comment, these reasons can be criticised individually but certainly not rejected especially if they are combined.9The role of comorbidities is crucial since they are present in over one half of the cases. Among these comorbidities, age is the most frequently cited but, in accordance with what is stated in the guidelines, it is very rarely the sole contraindication for intervention. The predictive value of the other parameters is insufficiently studied in the field of valve intervention and their value remains largely debatable. There are no precise recommendations on the contraindications for surgery in the field of VHD and the decision requires a careful individual weighing of each of these parameters after a multidisciplinary consultation. The multi-factorial nature of the decision process and the absence of clear guidance explains the wide variability of advice given. It is clearly a domain were it is difficult to make a meaningful comparison with guidelines. The way forward is probably to perform studies with more precise assessment of the risk using available risk scores.26,27
As regards the type of interventions performed, valve replacement remains the standard in aortic valve disease. There is an almost equal split between bioprostheses and mechanical valves in patients with AS. The higher proportion of mechanical prostheses in AR as compared to AS is the consequence of the greater proportion of younger patients in AR. The age threshold for choosing a bioprosthesis or a mechanical prosthesis remains a matter of debate.28In the current guidelines the threshold for choosing a mechanical valve over a bioprosthesis is 65.4In the survey there is a shift from 65 to 70 or 75. This trend is consistent with what was observed in the UK heart valve registry29and is probably an illustration that the decision making process cannot apply only to chronological age but should rather take into account a balance of several factors, including the cardiologists and surgeons preference. Valve repair, homograft or autograft valve replacement, which account for a large part of the contemporary surgical literature, are performed in only a small percentage of patients in real life.3032Finally, the data from the survey confirm that percutaneous aortic valvuloplasty has virtually disappeared frompractice.33
In mitral valve disease more conservative techniques are gaining popularity. In MR nearly half of the patients underwent mitral valve repair. This encouraging figure probably reflects the increasing confidence in the technique due to the accumulation of data showing its good short and long term efficacy.3436However, the answers of the physicians in the survey show that the absence of local expertise in conservative surgery remains a significant limitation for a larger use of conservative techniques. In the other patients, mechanical valves are usually preferred over bioprosthesis. In MS, the therapeutic alternatives are either percutaneous balloon commissurotomy, which is performed in over one third of cases, or prosthetic valve replacement, most often using a mechanical prosthesis.33Surgical commissurotomy has become an unusual procedure.37
Another characteristic of contemporary valve intervention is that it is frequently associated with other procedures.12,13This is particularly true in patients with aortic valve disease in whom an associated procedure is performed in between one third and half of cases. This is most often bypass grafting, while the use of combined percutaneous intervention remains exceptional in current practice.38The high frequency of concomitant lesions of the ascending aorta in degenerative AR explains why one fifth of patients who undergo surgery also require replacement of the ascending aorta.39Finally, associated anti-arrhythmic surgery is the subject of growing attention, in particular in patients with mitral valve disease, but very patients underwent this procedure in the survey.40
4.4. Operative mortality and morbidity
The risk of valve replacement was low in the aortic position. The risk of intervention in MS was very low due to the fact that a significant proportion of patients underwent balloon commissurotomy. As regards MR, our findings confirm the lower risk of valve repair in comparison with that of valve replacement, although selection bias may have partially accounted for this.34,35Consistent with other series, mortality was higher in patients where bypass grafting was associated, especially in mitral position.12,13However it should be stressed that combined surgery in MR frequently applies to patients who have ischaemic MR and whose operative mortality is always higher than in patients with other aetiologies.41
Overall mortality and morbidity figures after valve intervention observed in the survey are slightly lower than in the most recent surgical registries such as the STS database in the USA and the United Kingdom Cardiac Surgical Register (Table 9), but this may be related to differences in the centres involved.12,13,42,43The large proportion of medical centres in the survey may account for different patient characteristics and presentations as compared with registries comprising only surgical centres. In particular, only 2.0% of patients underwent emergency surgery in the present survey although the figure was 14% in the surgical registry from the UK12and this factor has a significant impact on operative mortality in VHD. In addition, the figures from the EHS and these registries are somewhat different from those of the current literature, but may not be strictly comparable as the survey represents a snapshot in 2001 whereas most literature series originate from selected centres and cover a long period of time during which changes in practice may have occurred.4446
4.5. Limitations
This survey was not a population-based epidemiological study and it is not possible to derive any information on the prevalence of different types of VHD, because the selection of participating centres may have introduced a selection bias. The results of this survey should therefore not be generalized to all centres within a particular country or region. On-site auditing concerned only a limited number of centres, and the audit only focused on the accuracy of data entry and not on the validity of the diagnosis. Although medical centres were required to enroll consecutive patients with VHD, we were not able to verify this due to our limited audit. Thirty-day follow-up status was missing for a small minority of patients and it was unlikely to affect mortality rates. Because patient management was based on the working diagnosis made by the attending physician, our analysis is suitable for the evaluation of patient management. Due to the nature of the survey and the limits of the existing guidelines, more than performing a strict head to head comparison with guidelines the aim was here to analyse the rationale for management
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5. Conclusions |
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Appendix A: Organisation of the Survey |
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Coordination and Data Management Centre (Euro Heart House, Sophia-Antipolis, France): Renaud Longelin (EHS Director); Malika Manini (EHS Operations Manager); Ronald Schravendeel, Charles Taylor (EHS Data Managers); Claire Bramley (EHS Data Monitor); Susan Del Gaiso (EHS Assistant).
Data Analysis Centre (Epidemiology, Biostatistic, and Clinical Research Department, BichatHospital, Paris, France): Philippe Ravaud, Gabriel Baron.
National Coordinators: Belgium, Guy De Backer; Switzerland, Peter Buser; Czech Republic, Roman Cerbak; Germany, Uwe Zeymer; Denmark, Per Thayssen; Spain, Angeles Alonso; Finland, Seppo Lehto; France, Jean-Jacques Blanc; United Kingdom, Kevin Fox; Greece, Dennis Cokkinos; Hungary, Kristof Karlocai; Israel, Sholmo Behar; Italy, Aldo Maggioni; Lithuania, Virginija Grabauskiene;Netherlands, Jaap W. Deckers; Poland, Janina Stepinska; Russia, Vyacheslav Mareev; Sweden, Annika Rosengren; Turkey, Tugrul Okay.
There was no national coordinator in the participating countries which are not mentioned in the above list.
Sponsors: European Society of Cardiology; Dutch Heart Foundation; Fédération Française de Cardiologie/Société Française de Cardiologie; Hellenic Cardiological Society; Swedish Heart and Lung Foundation; European Commission Grant (Infermed/Mansev Project); Toray MedicalCompany.
Participating Centres and Investigators with numbers of patients included per country: Czech Republic (627): J. Bruthans, Praha; J. Cerny, Brno; P. Bocek, Plzen. Spain (609): L. Lopez Bescos, Madrid; A. Castro Beiras, La Coruna; J.L. Diago Torrent, Castellon; F. Fernandez Avilés, Valladolid; F. Malpartida, Malaga; R. Melgares Moreno, Granada; J.A. Velasco Rami, Valencia; V. Palacios Motilla, Valencia; M. Soledad Alcasena Juango, Pamplona; A. Aloso Garcia, Madrid; C. MartinLuengo, Salamanca. Netherlands (557): J. Deckers, Rotterdam; F. Vermeer, R. Nieuwlaat, Maastricht; M.J. De Boer, Zwolle; J.W.M.G. Widdershofen, Tilburg; M. Bijl, Dordrecht. Israel (396): A. Sagie, Petach Tikva; B.S. Lewis, Haifa; D. Gilon, Jerusalem; W. Markiewicz, S. Rispler, Haifa; N. Roguin, Nahariya; N. Kogan, Nazareth; S. Shimoni, Rehovot; M. Leitman, Beer Yakov; C. Yosefy, Ashkelon; N. Liel-Cohen, Beer Sheva; C. Cafri, Beer Sheva. France (362): G. Montalescot, Paris; A. Cohen-Solal, Clichy; J.C. Daubert, Rennes; J.P. Bassand, Besançon. Lithuania (317): R. Jonkaitiene,Kaunas; A. Laucevicius, Vilnius. Germany (304): J. Niebauer, Leipzig; H. Klepzig, Offenbach; U. Zeymer, Kassel; R. Erbel, Essen; E. Fleck, Berlin; A. Gitt, Ludwigshafen am Rhein. Hungary (192): A. Temesvari, Budapest; K. Karlocai, Budapest; A. Kalina, F. Szaboki, Budapest; A. Katona, Gyula; A. Mohacsi, Debrecen. Finland (178): S. Lehto, Kuopio; M.S. Nieminen, Helsinki. Belgium (175): L. Piéard, V. Legrand, Liège; B. Marchandise, Yvoir. Italy (161): G. Rosano, Rome; F. Valagussa, Monza; D. di Marco, G. Levantesi, Vasto; E. Cecchi, Torino; A. Desideri, Castlefranco Veneto; C. Mazzone, Trieste. Greece (157): D. Cokkinos, Athens; S. Stametelopoulos, Athens; K. Oikonomou, P. Makridis, Edessa; M. Marketou, Heraklion; G.Psaltiras, Athens; C. Samara, Thessaloniki. Turkey (121): K. Sonmez, Istanbul; S. Aytekin, Sisli; J. Cordan, Bursa; B. Gorenek, Meselik-Eskisehir. Ukraine (121): Y.A. Ivaniv, Lviv; M. Orynchak, Ivano-Frankivsk. Romania (112): I.S. Benedek, Targu-Mures; E. Carasca, C. Suciu, Targu-Mures; G. Georgescu, Iasi; A. Iancu, Cluj-Napoca. Poland (105): M. Tendera, Katowice; A. Rynkiewicz, Gdansk; M. Trusz-Gluza, Katowice. United Kingdom (103): J.G.F. Cleland, Kingston-upon-Hull; M. Cowie, Aberdeen; D. Wood, London. Latvia (90): J. Romanova, Riga. Russia (85): A.A. Alexandrovsky, Saransk; D. Aronov, Moscow; A. Galiavitch, Kazan. Yugoslavia (74): M. Miric, Beograd; N. Radovanovic, Sremska Kamenica; B. Vujisic-Tesic, Belgrade.Denmark (60): P. Thayssen, Odense. Sweden (59): A. Rosengren, Göteborg; L. Rydén, Stockholm. Bulgaria (19): V. Sirakova, Varna. Switzerland (9): J. Turina, Zurich. Croatia (8): D. Pocanic, Zagreb.
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Appendix B: Definitions of terms |
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Hyperlipidemia: Diagnosis previously made by physician, receiving lipid-lowering therapy, or total cholesterol >190mg/dl or >5mmol/l, HDL <40mg/dl or <1mmol/l, TG >190mg/dl or >2mmol/l.
Hypertension: Diagnosis previously made by physician, receiving medications to lower blood pressure, or known blood pressure values of 140 mm Hg systolic or
90 mm Hg diastolic on
2 occasions.
Diabetes: Fasting blood glucose level 7mM/l. on
2 samples or previous diagnosis of diabetes, whatever the treatment.
Family history of premature coronary artery disease: History of angina pectoris, myocardial infarction, or sudden death among first-degree relatives before the age of 55 years.
Chronic obstructive pulmonary disease: Diagnosis previously made by physician, or patient receiving bronchodilators, or values of FEV1 <75% of expected value, arterial pO2 <60mmHg, or arterial pCO2 >50mmHg in prior studies.
Carotid atherosclerosis: stenosis >50%, previous or planned surgery.
Lower limbs atherosclerosis: claudication, previous or planned surgery.
Neurological dysfunction: neurological disease severely affecting ambulation or day-to-day.functioning.
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Acknowledgments |
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References |
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