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Aims: To establish a set of quality indicators (QIs) for the cardiovascular (CV) assessment and management of patients undergoing non-cardiac surgery (NCS)., Methods and Results: The Quality Indicator Committee of the European Society of Cardiology (ESC) and European Society of Anaesthesiology and Intensive Care (ESAIC) in collaboration with Task Force members of the 2022 ESC Guidelines on CV assessment and management of patients undergoing NCS followed the ESC methodology for QI development. This included (1) identification, by constructing a conceptual framework of care, of domains of the CV assessment, and management of patients with risk factors or established cardiovascular disease (CVD) who are considered for or undergoing NCS, (2) development of candidate QIs following a systematic literature review, (3) selection of the final set of QIs using a modified Delphi method, and (4) evaluation of the feasibility of the developed QIs. In total, eight main and nine secondary QIs were selected across six domains: (1) structural framework (written policy), (2) patient education and quality of life (CV risk discussion), (3) peri-operative risk assessment (indication for diagnostic tests), (4) peri-operative risk mitigation (use of hospital therapies), (5) follow-up (post-discharge assessment), and (6) outcomes (major CV events)., Conclusion: We present the 2022 ESC/ESAIC QIs for the CV assessment and management of patients with risk factors or established CVD who are considered for or are undergoing NCS y. These indicators are supported by evidence from the literature, underpinned by expert consensus, and align with the 2022 ESC Guidelines on CV assessment and management of patients undergoing NCS., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Russia has one of the highest rates of mortality from cardiovascular disease (CVD). At age 35-69 years, they are eight times higher than in neighbouring Norway. Comparing profiles of blood-based CVD biomarkers between these two populations can help identify reasons for this substantial difference in risk., Methods: We compared age-standardised mean levels of CVD biomarkers for men and women aged 40-69 years measured in two cross-sectional population-based studies: Know Your Heart (KYH) (Russia, 2015-2018; n=4046) and the seventh wave of the Tromsø Study (Tromsø 7) (Norway, 2015-2018; n=17 646). A laboratory calibration study was performed to account for inter-laboratory differences., Results: Levels of total, low-density lipoprotein-, high-density lipoprotein-cholesterol and triglycerides were comparable in KYH and Tromsø 7 studies. N-terminal pro-b-type natriuretic peptide (NT-proBNP), high-sensitivity cardiac troponin T (hs-cTnT) and high-sensitivity C-reactive protein (hsCRP) were higher in KYH compared with Tromsø 7 (NT-proBNP was higher by 54.1% (95% CI 41.5% to 67.8%) in men and by 30.8% (95% CI 22.9% to 39.2%) in women; hs-cTnT-by 42.4% (95% CI 36.1% to 49.0%) in men and by 68.1% (95% CI 62.4% to 73.9%) in women; hsCRP-by 33.3% (95% CI 26.1% to 40.8%) in men and by 35.6% (95% CI 29.0% to 42.6%) in women). Exclusion of participants with pre-existing coronary heart disease (279 men and 282 women) had no substantive effect., Conclusions: Differences in cholesterol fractions cannot explain the difference in CVD mortality rate between Russia and Norway. A non-ischemic pathway to the cardiac damage reflected by raised NT-proBNP and hs-cTnT is likely to contribute to high CVD mortality in Russia., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Background Alcohol drinking is an increasingly recognized risk factor for cardiovascular disease. However, there are few studies of the impact of harmful and hazardous drinking on biomarkers of myocardial health. We conducted a study in Russia to investigate the impact of heavy drinking on biomarkers of cardiac damage and inflammation. Methods and Results The Know Your Heart study recruited a random sample of 2479 participants from the population of northwest Russia (general population) plus 278 patients (narcology clinic subsample) with alcohol problems. The general population sample was categorized into harmful drinkers, hazardous drinkers, nonproblem drinkers, and nondrinkers, according to self-reported level of alcohol consumption, whereas the narcology clinic sample was treated as the separate group in the analysis. Measurements were made of the following: (1) high-sensitivity cardiac troponin T, (2) NT-proBNP (N-terminal pro-B-type natriuretic peptide), and (3) hsCRP (high-sensitivity C-reactive protein). The narcology clinic subsample had the most extreme drinking pattern and the highest levels of all 3 biomarkers relative to nonproblem drinkers in the general population: high-sensitivity cardiac troponin T was elevated by 10.3% (95% CI, 3.7%-17.4%), NT-proBNP by 46.7% (95% CI, 26.8%-69.8%), and hsCRP by 69.2% (95% CI, 43%-100%). In the general population sample, NT-proBNP was 31.5% (95% CI, 3.4%-67.2%) higher among harmful drinkers compared with nonproblem drinkers. Overall, NT-proBNP and hsCRP increased with increasing intensity of alcohol exposure (test of trend P <0.001). Conclusions These results support the hypothesis that heavy alcohol drinking has an adverse effect on cardiac structure and function that may not be driven by atherosclerosis.

The rapid increase of coronary heart disease mortality in Northern Norway during 1951-1970 was why the newly established University of Tromsø decided to start a study to identify major operating cardiovascular risk factors. The first Tromsø survey in 1974 suggested that the relatively high cardiovascular mortality was associated with elevated cholesterol levels and high prevalence of smoking, while high-density-lipoprotein-cholesterol (HDL-C) was identified as a preventive factor. After 1974, six more surveys including both genders (aged 20-89 years) were undertaken. The second survey (1979) revealed the cholesterol increasing effect of coffee. Echocardiographic examinations, ECG, and ultrasound of carotid arteries were introduced in later surveys, and intervention studies were established. Repeated carotid measurements showed that inflammation was involved in novel plaque formation, while HDL-C was protective. Moderate physical activity protected against atrial fibrillation but hard exercise increased the risk. Obesity, hypertension and smoking increased the risk of aortic stenosis, and diastolic dysfunction predicted development of atrial fibrillation. Dilated left atria predicted stroke, especially for individuals without known atrial fibrillation. Total cholesterol, blood pressure and smoking declined after 1974, corresponding to the subsequent decline in coronary heart disease mortality. Reduced incidence accounted for 40% of the mortality decline, while a substantial reduction in case fatality explained the remaining 60%.

Aims: Ultrasound-derived myocardial strain can render valuable diagnostic and prognostic information. However, acquisition settings can have an important impact on the measurements. Frame rate (i.e. temporal resolution) seems to be of particular importance. The aim of this study was to find the optimal range of frame rates needed for most accurate and reproducible 2D strain measurements using a 2D speckle-tracking software package., Methods and Results: Synthetic two dimensional (2D) ultrasound grey-scale images of the left ventricle (LV) were generated in which the strain in longitudinal, circumferential, and radial direction were precisely known from the underlying kinematic LV model. Four different models were generated at frame rates between 20 and 110 Hz. The resulting images were repeatedly analysed. Results of the synthetic data were validated in 66 patients, where long- and short-axis recordings at different frame rates were analysed. In simulated data, accurate strain estimates could be achieved at >30 frames per cycle (FpC) for longitudinal and circumferential strains. Lower FpC underestimated strain systematically. Radial strain estimates were less accurate and less reproducible. Patient strain displayed the same plateaus as in the synthetic models. Higher noise and the presence of artefacts in patient data were followed by higher measurement variability., Conclusion: Standard machine settings with a FR of 50-60 Hz allow correct assessment of peak global longitudinal and circumferential strain. Correct definition of the region of interest within the myocardium as well as the reduction of noise and artefacts seem to be of highest importance for accurate 2D strain estimation., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.)

Importance: Identification of structural heart disease in asymptomatic individuals could allow early disease-modifying treatment., Objective: To examine whether echocardiographic screening in the general population improves long-term survival or reduces the risk of cardiovascular disease., Design, Setting, and Participants: We studied 6861 middle-aged participants from the population-based Tromsø Study in Norway., Intervention: Participants were randomly allocated to an echocardiographic screening group (n = 3272) or a control group (n = 3589)., Main Outcomes and Measures: Using the as-treated approach, the data were analyzed for mortality and incidence of fatal and nonfatal myocardial infarction and stroke., Results: During 15 follow-up years, 880 persons (26.9%) in the screening group and 989 persons (27.6%) in the control group died (hazard ratio, 0.97; 95% CI, 0.89-1.06). No significant differences between the groups were observed in the secondary outcome measures (sudden death, mortality from any heart disease, or incidence of fatal and nonfatal myocardial infarction and stroke)., Conclusions and Relevance: Echocardiographic screening for structural and valvular heart disease in the general population provided no benefit for mortality or for the risk of myocardial infarction or stroke.

Aims: To investigate changes in cardiovascular risk factors over 14 years in relation to diabetes status., Methods: The study is based on 10,327 subjects who attended the Tromsø Study in 1994 and were screened again in 2007-8. At baseline there were 79 prevalent cases, and 397 incident cases of type 2 diabetes mellitus (DM2) were diagnosed between 1994 and 2008., Results: Cases with DM2 had decreasing levels of high-density lipoprotein cholesterol (HDL-C), total cholesterol and blood pressure (BP) and increasing levels of triglycerides, body mass index (BMI), and anti-hypertensive treatment during 14 years of follow-up. Despite decreasing BP, more than 75% of the treated cases had BP above 135/80 at the end of follow-up. Similarly, less than 35% of incident cases using statins had low-density lipoprotein cholesterol (LDL-C) below the recommended threshold value of 2.6 mmol/l., Conclusions: Despite greater relative reduction in cardiovascular risk factors among people with DM2 compared to those without, treatment targets were met in less than 50% of subjects with DM2. Thirteen percent reached the combined targets for glucose, BP and LDL-C control. This indicates a need for more effective strategies to control cardiovascular risk factors especially among individuals with DM2.

Background and Purpose: The role of cardiovascular risk factors in the pathogenesis of cognitive impairment and dementia remains still unclear. We examined the impact of cardiovascular risk factors on cognitive function in a large longitudinal population study., Methods: Subjects were 5033 stroke-free men and women who participated in a longitudinal population-based study. Cardiovascular risk factors were measured at baseline, and cognitive function was assessed after 7 years of follow-up with verbal memory test, digit-symbol coding test, and tapping test., Results: Diabetes, systolic blood pressure, and current smoking were independently associated with lower cognitive test results in men and women. Low physical activity was independently associated with lower scores in women. We found no consistent association between total-cholesterol, HDL-cholesterol, coronary heart disease or BMI, and cognitive test results., Conclusions: Diabetes, smoking, hypertension, and low physical activity were associated with lower cognitive test results. The study suggests that these modifiable risk factors should be emphasized in the prevention of cognitive decline., (© 2010 The Author(s). European Journal of Neurology © 2010 EFNS.)

Objective: To study the impact of endogenous testosterone levels in community-dwelling men on later risk for myocardial infarction (MI) and all-cause, cardiovascular disease (CVD), and ischemic heart disease (IHD) mortality., Design: Population-based prospective cohort study., Methods: For the analyses, we used a cohort of 1568 randomly selected men, with sex-hormone data participating in the fourth Tromsø Study (1994-1995). Defined end points were first-ever MI (fatal or nonfatal), all-cause, CVD, and IHD mortality. A committee performed thorough ascertainment of end points, following a detailed protocol. Complete ascertainment of end points was until 30 September 2007 for all-cause mortality, until 31 December 2005 for CVD/IHD mortality, and until 31 December 2004 for first-ever MI. The prospective association between total and free testosterone and end points were examined using Cox proportional hazard regression, allowing for multivariate adjustment for age and cardiovascular risk factors., Results: During follow-up, there were 395 deaths from all causes, 130 deaths from CVD and 80 deaths from IHD, while 144 men experienced a first-ever MI. There was a significant increase in all-cause mortality risk for men with free testosterone in the lowest quartile (<158 pmol/l) compared with the higher quartiles after age adjustment hazard ratios (HR 1.24, 95% confidence interval, CI 1.01-1.53) and after multivariate adjustments (HR 1.24, 95% CI 1.01-1.54). Total testosterone was not associated with mortality risk. Likewise, there were no significant changes in risk for first-ever MI across different total or free testosterone levels., Conclusion: Men with free testosterone levels in the lowest quartile had a 24% increased risk of all-cause mortality.

Tracking of cardiovascular risk factors (blood pressure, body mass index (BMI), and serum lipids) has not been studied much in a general, adult population. No known study has compared tracking of these factors for both sexes. In the present study, 17,710 men and women aged 20-61 years at baseline attended two or three population-based health surveys in Tromsø, Norway, over 16 years (between 1979-1980 and 1994-1995). Tracking coefficients were estimated by using different methods, and possible predictors of tracking were found. There was a high degree of tracking for BMI (overall tracking coefficients: 0.85 for men, 0.80 for women). Relatively high (or moderate) tracking was found for systolic blood pressure (respective sex-specific coefficients: 0.52, 0.54), diastolic blood pressure (0.48, 0.48), high density lipoprotein cholesterol (0.55, 0.64), and total cholesterol (0.77, 0.65). The lowest coefficients were for triglycerides (0.43, 0.39). Analysis of tracking in the upper sextile confirmed these results. Although some baseline predictors were associated with tracking, the effects were relatively weak. When predictors for tracking in the upper sextile were assessed, significant associations were found with relatively strong effects. No major sex differences were observed in tracking. However, women were more likely than men to remain in the upper sextile of systolic and diastolic blood pressures and of BMI.

Ebbing M., Bønaa K.H., Arnesen E., Ueland P.M., Nordrehaug J.E., Rasmussen K., Njølstad I., Nilsen D.W., Refsum H., Tverdal A., Vollset S.E., Schirmer H., Bleie Ø., Steigen T., Midttun Ø., Fredriksen Å., Pedersen E.R., Nygård O. (From the Departments of 1Heart Disease, Haukeland University Hospital, Bergen; Heart Disease, University Hospital of North Norway; Department of Community Medicine, University of Tromsø, Tromsø; Institute of Medicine, University of Bergen, Bergen; Department of Clinical Medicine, University of Tromsø, Tromsø; Department of Cardiology, Stavanger University Hospital, Stavanger; Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway; Department of Physiology, Anatomy & Genetics, University of Oxford, Oxford, UK; Division of Epidemiology, the Norwegian Institute of Public Health, Oslo; Department of Public Health and Primary Health Care, University of Bergen; Bevital AS, Bergen; Norway) Combined Analyses and Extended Follow-Up of Two Randomized Controlled Homocysteine-Lowering B-Vitamin Trials. J Intern Med 2010; 268: 367–382. Objectives. In the Norwegian Vitamin Trial and the Western Norway B Vitamin Intervention Trial, patients were randomly assigned to homocysteine-lowering B-vitamins or no such treatment. We investigated their effects on cardiovascular outcomes in the trial populations combined, during the trials and during an extended follow-up, and performed exploratory analyses to determine the usefulness of homocysteine as a predictor of cardiovascular outcomes. Design. Pooling of data from two randomized controlled trials (1998–2005) with extended post-trial observational follow-up until 1 January 2008. Setting. Thirty-six hospitals in Norway. Subjects. 6837 patients with ischaemic heart disease. Interventions. One capsule per day containing folic acid (0.8 mg) plus vitamin B12 (0.4 mg) and vitamin B6 (40 mg), or folic acid plus vitamin B12, or vitamin B6 alone or placebo. Main outcome measures. Major adverse cardiovascular events (MACEs; cardiovascular death, acute myocardial infarction or stroke) during the trials and cardiovascular mortality during the extended follow-up. Results. Folic acid plus vitamin B12 treatment lowered homocysteine levels by 25% but did not influence MACE incidence (hazard ratio, 1.07; 95% CI, 0.95–1.21) during 39 months of follow-up, or cardiovascular mortality (hazard ratio, 1.12; 95% CI, 0.95–1.31) during 78 months of follow-up, when compared to no such treatment. Baseline homocysteine level was not independently associated with study outcomes. However, homocysteine concentration measured after 1–2 months of folic acid plus vitamin B12 treatment was a strong predictor of MACEs. Conclusion. We found no short- or long-term benefit of folic acid plus vitamin B12 on cardiovascular outcomes in patients with ischaemic heart disease. Our data suggest that cardiovascular risk prediction by plasma total homocysteine concentration may be confined to the homocysteine fraction that does not respond to B-vitamins. [ABSTRACT FROM AUTHOR]