BACKGROUND:Despite treatment, many hypertensive patients with coronary heart disease (CHD) have blood pressure (BP) that remains above guideline targets. However, less is known about patients in whom on-treatment BP is below target and major European guidelines differ substantially in their recommendations for such patients. Specifically, 2023 European Society of Hypertension (ESH) guidelines provide a Class 3 recommendation to proactively avoid BP below target whereas 2024 European Society of Cardiology (ESC) guidelines do not. METHODS:Between 2020 and 2023, adults hospitalised in the previous 6-24 months with incident or recurrent CHD were sampled in 14 countries from all six WHO regions and invited for a standardised interview and examination as part of the International Action on Secondary and Primary Prevention by Intervention to Reduce Events (INTERASPIRE) study. We measured seated BP twice using an automated oscillometric device after 5 min of rest. We defined participants as having BP above target (BP ≥130/80 mm Hg), at target (BP 120-129/70-79 mm Hg) or below target (<120/70 mm Hg); according to both 2023 ESH and 2024 ESC guidelines. RESULTS:Among 4548 participants (21.1% female), the mean age (±SD) was 60.0 (±10.3) years. At a median (IQR) of 1.05 (0.76-1.45) years after index CHD hospitalisation, 10.3% of patients had BP readings within the target range of 120-129/70-79 mm Hg, with 53.9% above target and 35.7% below target. Patients with below-target BP were more likely to have heart failure (13.6% vs 10.0%, p=0.041) and estimated glomerular filtration rate <60 mL/min/1.73 m² (18.9% vs 10.7%, p<0.001), when compared with those at target. They were also statistically more likely to be severely frail (p=0.030). The median number of BP-lowering medications did not differ significantly between the 3 BP target groups. Cumulative dosing of BP-lowering medications in the below-target group was also not more intensive than that in the at-target group. CONCLUSIONS:More than one-third of INTERASPIRE patients with CHD presented with BP <120/70 mm Hg, which is below target per current European hypertension guidelines. Further research is needed in this population to resolve discordant guideline recommendations and determine whether de-escalation of BP-lowering therapies is beneficial or even harmful in this setting.

BACKGROUND:Chronic kidney disease (CKD) is an important risk factor for the progression of coronary artery disease (CAD). OBJECTIVES:The purposes of this study were to quantify the prevalence of CKD in CAD patients from 14 countries from all World Health Organization regions and to evaluate the prognostic value of estimated glomerular filtration rate (eGFR) and urinary albumin/creatinine ratio (UACR). METHODS:A total of 4,548 patients with CAD were included (79.6% were males; age range: 18-80 years). They were assessed for eGFR and UACR 6 to 24 months after the CAD diagnosis. Complete information on kidney function and cardio-renal protective therapy was available for 3,865 patients and follow-up data after a median of 1 year were available for 3,577 (92.5%). RESULTS:CKD according to the Kidney Disease Improving Global Outcomes classification was present in 32% of whom 19.7% were classified as low-moderate, 6.9% as high, and 5.6% as very high risk. Without UACR, 51.3% of them would have been undetected. The primary event, first of cardiovascular death, myocardial infarction, stroke, and hospitalization for heart failure, was observed in 7.9%, with the highest incidence in the Kidney Disease Improving Global Outcomes high-risk group (men: 13.0%; women: 11.8%). This relationship was independent of other risk factors and evident soon after the index examination. Only a minority of the patients received adequate cardio-renal protective therapy. CONCLUSIONS:Early screening for CKD in patients with CAD is important and should preferably include both eGFR and UACR to provide a complete diagnosis. Without UACR, half of those with CKD would remain undetected. Treatment with cardio-renal protective therapy was low, providing great potential for improvement.

AIMS:To study the associations of dietary intake of A and E vitamins, as well as plasma retinols, carotenoids, and tocopherols in relation to development of islet autoimmunity and progression to T1D. MATERIALS AND METHODS:The Environmental Determinants of Diabetes in the Young (TEDDY) Study followed 7659 newborns with genetic susceptibility to T1D for 6 years in the USA, Finland, Germany, and Sweden. Dietary vitamin intake was assessed repeatedly with 3-day food-records in full cohort at ages 6 months to 6 years. Plasma retinols, carotenoids, and tocopherols were analysed in a nested case-control setting with 359 children with islet autoimmunity and 1033 matched controls. RESULTS:In the full cohort analyses, dietary intake of retinol, β-carotene, and vitamin E was not associated with the risk of islet autoimmunity or progression to T1D. Further, none of the plasma retinol, carotenoid, and tocopherol biomarkers were associated with islet autoimmunity or T1D in the full nested case-control analyses. We observed effect modification by country, breastfeeding, sex, and follow-up time for both intake and biomarkers of vitamins on the risk of islet autoimmunity or T1D, and some subgroup associations. Finally, a plasma carotenoid metabolite (likely zeinoxanthin) (OR 0.61, 95% CI 0.39, 0.95, p = 0.03) and γ-carotene at 6 months (OR 0.65, 95% CI 0.45, 0.94, p = 0.02) were inversely associated with the odds of developing GADA-first. CONCLUSIONS:Retinol, carotenoids and tocopherols were not consistently associated with islet autoimmunity. This study adds to the understanding of factors and their interactions related to T1D development.

BACKGROUND:Optimizing health-related quality of life (HRQoL) is a goal of preventive and therapeutic cardiovascular care worldwide, yet sex disparities in HRQoL remain insufficiently explored at a population level. The objective of this study was to examine sex differences in HRQoL in relation to secondary prevention in patients with CHD across all six World Health Organization regions. METHODS:Cross-sectional analysis of the INTERASPIRE study of adults hospitalized in the preceding six to 24 months with CHD who underwent standardized interview and examination across 14 countries. Endpoints were HRQoL (EQ-5D-5L; HeartQoL), and an INTERASPIRE-Guideline Target Score (GTS); a 10-point assessment of achieving secondary prevention lifestyle, risk factor, and therapeutic targets. Analyses were adjusted for age and country-level clustering. RESULTS:A total of 4546 patients (21.1% women) were interviewed. Compared to men, women had lower HRQoL across all assessments (p < 0.001) e.g., mean HeartQoL global score 2.1 vs 2.6; EQ-5D-5L self-care 17.8% vs 9.2%, and usual activities 39.1% vs 22.4%. Positive correlations (p < 0.001) were identified between HRQoL and INTERASPIRE-GTS. Female sex was independently associated with poor HRQoL (p < 0.001), either expressed by EQ-5D-5L index score or the HeartQoL overall and subscale scores. CONCLUSIONS:Female sex was independently associated with poorer HRQoL in patients with CHD. Higher HRQoL was associated with ability to achieve secondary prevention guideline targets. Routine integration of HRQoL assessment into secondary prevention programs can inform individualized clinical care and assist in reducing sex-based disparities in cardiovascular outcomes.

BACKGROUND:Lipoprotein(a) [Lp(a)] is a common risk factor for atherosclerotic cardiovascular disease, potentially more atherogenic per particle than low-density lipoprotein. An estimated 1.5 billion individuals globally have elevated levels ≥125 nmol/L, considered as a risk-enhancing threshold. Although Lp(a) levels vary by ethnicity, ongoing trials of novel therapies in predominantly secondary prevention patients use fixed Lp(a) enrollment thresholds. OBJECTIVES:The purpose of this study was to assess Lp(a) levels in coronary heart disease (CHD) patients across geographical regions, providing inference on the proportions potentially eligible for future Lp(a)-lowering therapies and whether these vary by region and country. METHODS:INTERASPIRE (International Action on Secondary Prevention through Intervention to Reduce Events)enrolled adults hospitalized with CHD in the previous 6 to 24 months. Lp(a) levels were available in 13 countries across 6 World Health Organization (WHO) regions: Africa (Kenya, Nigeria, Tanzania), Americas (Argentina, Colombia), Eastern Mediterranean (UAE), Europe (Poland, Portugal), South-East Asia (Indonesia), and Western Pacific (China, Malaysia, Philippines, Singapore). Lp(a) measurements were performed once and centrally in Helsinki using an isoform-independent assay for 11 countries, and locally in Indonesia and China with standardization to the core laboratory. Lp(a) levels are reported as median (Q1-Q3) and proportions above different thresholds. RESULTS:Lp(a) results were available for 3,928 patients from 13 countries (mean age: 60.2 ± 10.2 years; 21.1% women). Median Lp(a) was 32 nmol/L (Q1-Q3: 11-89 nmol/L) overall, with 17.6% having levels ≥125 nmol/L. Median levels varied by region-highest in Africa (62 nmol/L) and lowest in Western Pacific (22 nmol/L)-and also between countries within regions: Europe (Portugal: 59 nmol/L vs Poland: 19.5 nmol/L), South America (Colombia: 46 nmol/L vs Argentina: 32 nmol/L) and Western Pacific (Malaysia: 39.5 nmol/L vs Philippines: 14 nmol/L). Overall, the proportions of patients with Lp(a) ≥150, 175, and 200 nmol/L (hence eligibility for future Lp(a)-lowering therapies) were 13.0%, 9.3%, and 6.2%, respectively, with eligibility also varying among countries: highest in Portugal (25.5%, 18.3%, and 11.6%) and lowest in Philippines (4.3%, 2.5%, and 1.3%). CONCLUSIONS:The vast majority of patients with CHD have Lp(a) levels far below what is considered a typical risk-enhancing threshold, suggesting that the attributable risk from Lp(a) is more complex than previously perceived. Furthermore, wide geographical variations in Lp(a) levels above entry criteria for ongoing trials could impact equitable access to therapies, if these trials are positive.

AIMS:Anxiety and depression are associated with poor outcomes in patients with coronary heart disease (CHD), however their association with achieving recommended cardiovascular prevention standards is unclear. We examined this association across all World Health Organization regions. METHODS:Cross-sectional analysis of the INTERASPIRE study of adults hospitalized in the preceding 6 to 24 months with incident or recurrent CHD who underwent a standardized interview and examination (2020 to 2023) across 14 countries. The main outcome was the INTERASPIRE-Guideline Target Score (GTS); a 10-point assessment of achieving secondary prevention lifestyle, risk factor, and therapeutic targets. RESULTS:A total of 4546 patients (21.1% women) with a mean (SD) age of 60.0 (10.3) were interviewed. Prevalence's of anxiety and/or depression were greater in women than men, and prevalence of CHD lifestyle and behavioral risk factors increased alongside severity of anxiety and depression symptoms. Compared to those without symptoms, adjusted odds ratios for achieving a suboptimal INTERASPIRE-GTS were: 1.52 (95% CI 1.13-2.04, p = 0.006) for symptoms of depression; 1.57 (95% CI 1.09-2.26, p = 0.015) for 'possible' comorbid anxiety and depression; and 2.09 (95% CI 1.22-3.57, p = 0.007) for those with 'probable' comorbid anxiety and depression. CONCLUSION:Increasing severity of depression and anxiety symptoms are associated with reduced potential for achieving guideline standards for CHD secondary prevention. Secondary prevention programs should integrate risk-stratified management of individuals with symptoms of anxiety and/or depression to improve CHD guideline targets.

Dysglycaemia, defined as type 2 diabetes mellitus (T2DM) or impaired glucose tolerance (IGT), increases the cardiovascular risk and prognosis. INTERASPIRE performed in 14 countries across 6 WHO regions evaluated guideline adherence and management of patients with coronary artery disease (CAD) and dysglycaemia. A total of 4,548 CAD patients (18–80 years) were interviewed 6 months–2 years after hospital admission. All without diabetes were eligible for an oral glucose test (OGTT). Overall, 1990 (44

Background Prevalent manifestation of metabolic dysfunction, metabolic dysfunction-associated steatotic liver disease (MASLD), has been associated with poorer cognitive performance and greater decline in cognitive functions. Aim The aim of this study was to analyze whether MASLD, measured by fatty-liver-index (FLI), predicts decline in cognitive performance during 11 years. Methods This study was based on the Finnish nationwide, population-based Health 2000 Health Examination Survey and its follow-up, Health 2011 Survey. Cognitive performance was assessed with verbal fluency, word-list learning (WLL), delayed word-list recall (both at baseline and at follow-up), and with simple reaction time and visual choice reaction time tests (only at baseline). Statistical analyses were performed using multivariate linear regression adjusted for age, sex, education, APOE ε4 genotype, hypercholesterolemia, diabetes mellitus, hypertension, depressive symptoms, physical activity smoking status, C-reactive protein and HOMA of insulin resistance. Results Cross-sectionally, 5,139 (mean age 52.3 years) and longitudinally, 3,143 (mean age 49.3 years) participants were examined. Cross-sectionally, no associations between FLI and cognitive performance were found in the adjusted models. Longitudinally, baseline FLI > 60 predicted poorer WLL (p < 0.005) and a decline in WLL from baseline to follow-up (p < 0.04). Conclusions Our results suggest that MASLD is an independent predictor of decline in a test measuring working memory and learning.

AIMS:To quantify international variations in lipid-lowering therapies (LLT) use among patients with coronary heart disease (CHD) and attainment of European guideline-recommended lipid goals. METHODS AND RESULTS:INTERASPIRE is an observational study (2020-23) covering 14 countries from all WHO regions. Patients (18-79 years) hospitalized in the preceding 6-36 months with CHD were invited for standardized interviews and examination, with central laboratory analyses for low-density lipoprotein cholesterol (LDL-C), non-HDL-C, and apolipoprotein B (apoB). Valid lipid data meeting quality control standards were available from 13 countries. Lipid goals followed the 2019 guidelines of the European Atherosclerosis Society and the European Society of Cardiology: LDL-C < 1.4 mmol/L, non-HDL-C < 2.2 mmol/L, and apoB <65 mg/dL.Among 4061 patients (78.8% male, mean age 60.3 years), between index event and interview, 66.3% had no change in treatment intensity. LLT use at interview was largely statin monotherapy: 49.6% high-intensity (inter-country range 5.3%-77.3%) and 24.1% low/moderate-intensity (inter-country range 5.1%-70.1%). Otherwise, 12.2% (inter-country range 0.2%-41.1%) were on combination therapy, and 12.7% on no LLT (inter-country range 3.5%-36.7%). Goal attainment for LDL-C was 17.5%. Corresponding non-HDL-C and apoB goals were achieved by 29.9% and 29.2%, respectively. Higher-income countries (defined by the World Bank's 2024-25 classification of income levels) did better in goal attainment than lower-middle-income countries. CONCLUSION:In this international study, contemporary lipid goals were not achieved in most CHD patients, with lower-middle-income countries having the worst goal attainment. Contributory factors include absence of any LLT use, low use of combinations and a failure to up-titrate LLT to achieve guideline targets.

BACKGROUND AND AIMS:The enhanced liver fibrosis (ELF) test has good discrimination performance in detecting advanced liver fibrosis. The chronic liver disease (CLivD) risk score based on clinical data accurately predicts risk for future severe liver disease. Considering the ELF test as a surrogate marker for liver fibrosis, we analyzed predictors of elevated ELF (eELF) and its change. METHODS:The study cohort consisted of Finnish general population-based health surveys Health2000 and a follow-up study 10 years later Health2011 with 6084 and 2937 individuals, respectively with phenotype and ELF data. eELF was defined as ELF ≥ 9.8, and clinically relevant fibrosis progression as an ELF change ≥0.6. CLivD risk score was calculated at baseline. Analyses were age-adjusted. RESULTS:Obesity measures and diabetes predicted eELF at baseline. Only waist-hip ratio (WHR) could predict clinically relevant fibrosis progression over the follow-up consistently among men and women (OR 1.35 and 1.41, respectively). High-risk alcohol use was a significant risk factor for eELF only among men (OR 1.72, p = 0.049), and it did not predict fibrosis progression in either sex. Although elevated transaminases were associated with eELF, in most individuals with eELF they were within reference limits. Increased CLivD scores correlated with baseline and the change of ELF values over the 10-year follow-up independent of baseline ELF (p < 0.001). CONCLUSIONS:Liver fibrosis progression is difficult to predict based on single risk factors or liver enzymes. ELF had limited value to predict fibrosis progression. The CLivD score, based on multiple risk factors, predicted both occurrence of baseline eELF and its progression over a 10-year follow-up.

INTRODUCTION:The use of combined oral contraceptives (COCs), but not of progestin-only pills (POPs) is associated with an increased risk of cardiovascular events. A detailed examination of how different oral contraceptives impact the metabolism in the short- and long-term has not been conducted. This study comparatively examines cross-sectional and longitudinal metabolomics-based profiles of different COCs and POPs, and explores how they perform relative to a metabolically safer contraceptive option. MATERIAL AND METHODS:Data were obtained from a population-based survey (Health 2000) and its 11-year follow-up (Health 2011). Altogether, 212 metabolic measures in OC users (n = 299; COC, n = 245; POP, n = 33) were compared to those in non-users of hormonal contraception (HC; n = 1422), and in users of a levonorgestrel intrauterine device (LNG-IUD; n = 341) via multivariable general estimating equations models adjusted for age, body mass index, duration of use, study cohort, diseases, medication use, alcohol use, smoking, and physical activity. Participants with complete longitudinal information (n = 327) were divided into continuers, stoppers, starters, switchers, and never-user groups, and the 11-year changes in the levels of each metabolite were compared. RESULTS:Use of COCs, but not of POPs, was associated with altered levels of several metabolic measures compared to HC non-use or to use of LNG-IUD: higher concentrations and ratios of monounsaturated fatty acids but lower ratios of polyunsaturated fatty acids, and higher concentrations and ratios of triglycerides in lipoproteins. Additionally, in comparison to HC non-use or to use of LNG-IUD, users of third generation or other COCs had higher levels of inflammation markers and of cholesterol, but a lower percentage of cholesterol and a higher percentage of triglycerides in lipoproteins. Continuation or starting of LNG-IUD was not related to changes in metabolic profiles, while women who changed or stopped using COCs had greater levels of unsaturation and lower levels of total and lipoprotein triglycerides and other lipids. CONCLUSIONS:The use of COCs, especially of third generation and other COCs, is related to various metabolic alterations suggestive of increased cardiovascular risk. Conversely, the use of POPs and LNG-IUD appeared metabolically safe. These associations were mostly reversible after interruption of use or switch to different preparations.

Background:INTERASPIRE was an observational study of patients with coronary heart disease (CHD) from 88 hospitals in 14 countries across all six WHO regions. The objective was to describe the proportions of patients referred to and attending cardiac rehabilitation (CR) programmes and to compare lifestyle and risk factor target achievement according to participation in a CR programme. Methods:Patients 18-80 years of age, with a first or recurrent coronary hospitalisation (acute coronary syndrome and/or revascularisation procedure) were identified and invited to an interview and examination, between six months and two years after the index hospitalisation. Results:Overall, 4,548 (21.1% female) patients were interviewed a median of 1.05 (interquartile range 0.76-1.45) years after hospitalization. Of those patients, 34.4% reported having been advised to participate in a CR programme, though the percentage varied widely by country, from 4.0% in Kenya to 69.6% in Poland. Among patients advised to participate in CR, 57.1% participated in ≥50% of all sessions, 15.4% participated in <50% of the sessions, and 27.4% did not participate at all. Only 19.6% of all patients recruited to the study attended ≥50% of sessions. Content of programmes reported by patients also varied enormously between countries. Low education level, elective PCI, or unstable angina as recruiting events were associated with lower attendance rates. Attendance at ≥50% of all CR sessions was associated with a lower prevalence of persistent smoking and physical inactivity, better control of blood pressure and LDL-cholesterol, and a higher use of cardioprotective medications. Conclusions:INTERASPIRE provides a standardised international picture of CR provision and attendance in patients with CHD. Despite CR being a Class 1 recommendation in all international guidelines, only one third of CHD patients reported being advised to attend any form of CR and just one in five patients attended 50% of the sessions, with striking heterogeneity between regions and countries. National cardiology societies should advocate to their governments for urgent investment in standardised CR services.

BACKGROUND AND AIMS:Hypertriglyceridemia (HTG) is independently associated with risk of atherosclerotic events, even when LDL-cholesterol levels appear controlled. This INTERASPIRE study determined the frequency of HTG and residual combined dyslipidemia and their related factors in patients with coronary heart disease (CHD) from 13 countries across six World Health Organization (WHO) regions. METHODS:Participants with CHD underwent a standardized study interview and examination, including a centralized analysis of fasting blood samples. Elevated triglyceride (TG) and LDL-cholesterol were defined as ≥ 1.7 mmol/L and 1.8 mmol/L, respectively. Elevation in both was considered combined dyslipidemia. RESULTS:Lipid profiles were available for 4069 patients. The mean age was 60.1 years (21.1 % women, 12.6 % smokers, 24 % obesity by body mass index [BMI], 61 % hypertension, and 44 % self-reported diabetes). Participants were evaluated 1.05 (0.76-1.45) years after their index CHD hospitalization. Overall, 12.7 % used no lipid-lowering therapies (LLT), 50.0 % used high-dose statins, and 11.8 % used combination therapies. Specific TG-lowering therapies were used by 2.3 %. One-third of patients had HTG, and 24.6 % had combined dyslipidemia. HTG was seen in all countries, but median TG values varied, with higher values among those not using LLT. HTG was independently associated with female sex, smoking, BMI, blood pressure, and LDL-cholesterol. HTG was inversely associated with HDL-cholesterol. CONCLUSIONS:HTG and residual combined dyslipidemia are common, although with wide variability between countries. A healthier lifestyle, weight reduction, greater use of combination therapy, and evidence-based TG-lowering treatments are necessary to reduce the risks of HTG and combined dyslipidemia.

Background Maternal 25-hydroxyvitamin D (25OHD) status has been associated with birth weight and childhood growth. Further, maternal 25OHD status may also influence cardiometabolic outcomes in childhood. This study investigated the association between maternal 25OHD concentration in pregnancy and markers of cardiometabolic risk in 7-12-year-old children.Methods Data were obtained from the Norwegian Environmental Biobank (NEB) including 244 mother-child pairs in the Norwegian Mother, Father and Child Cohort Study (MoBa) participating in NEB part I and II. Childhood outcomes investigated were z-scores of anthropometrics, blood lipids and hormones. Associations between maternal 25OHD and individual cardiometabolic risk factors in children were assessed by linear regression, adjusted for maternal pre-pregnancy BMI, maternal education, child's sex, age and BMI, and tested for interaction with pre-pregnancy BMI.Results Per 10 nmol/L increase in maternal 25OHD, childhood adiponectin z-score increased by 0.067 standard deviations (p = 0.039). There were no associations between maternal 25OHD concentration and any other cardiometabolic risk factor in childhood.Conclusion The results indicate that higher maternal vitamin D status during pregnancy may be related to higher childhood adiponectin z-score, but not with any other cardiometabolic risk marker. Whether adiponectin could be one pathway linking vitamin D to cardiometabolic health remains to be determined.

Background and Aims INTERASPIRE is an international study of coronary heart disease (CHD) patients, designed to measure if guideline standards for secondary prevention and cardiac rehabilitation are being achieved in a timely manner. Methods Between 2020 and 2023, adults hospitalized in the preceding 6-24 months with incident or recurrent CHD were sampled in 14 countries from all 6 World Health Organization regions and invited for a standardized interview and examination. Direct age and sex standardization was used for country-level prevalence estimation. Results Overall, 4548 (21.1% female) CHD patients were interviewed a median of 1.05 (interquartile range .76-1.45) years after index hospitalization. Among all participants, 24.6% were obese (40.7% centrally). Only 38.6% achieved a blood pressure (BP) < 130/80 mmHg and 16.6% a LDL cholesterol (LDL-C) of <1.4 mmol/L. Of those smoking at hospitalization, 48% persisted at interview. Of those with known diabetes, 55.2% achieved glycated haemoglobin (HbA1c) of <7.0%. A further 9.8% had undetected diabetes and 26.9% impaired glucose tolerance. Females were less likely to achieve the targets: BP (females 36.8%, males 38.9%), LDL-C (females 12.0%, males 17.9%), and HbA1c in diabetes (females 47.7%, males 57.5%). Overall, just 9.0% (inter-country range 3.8%-20.0%) reported attending cardiac rehabilitation and 1.0% (inter-country range .0%-2.4%) achieved the study definition of optimal guideline adherence. Conclusions INTERASPIRE demonstrates inadequate and heterogeneous international implementation of guideline standards for secondary prevention in the first year after CHD hospitalization, with geographic and sex disparity. Investment aimed at reducing between-country and between-individual variability in secondary prevention will promote equity in global efforts to reduce the burden of CHD.

This survey of secondary prevention of CVD was conducted through National Societies of Cardiology across all WHO regions and included Kenya, Nigeria, Tanzania, Argentina, Colombia, Egypt, UAE, Poland, Portugal, Indonesia, China, Malaysia, Philippines and Singapore. The overall aim of INTERASPIRE was to assess the clinical implementation of risk reduction initiatives to reduce cardiovascular risk in line with lifestyle, risk factor and therapeutic targets defined in international and national guidelines on CVD prevention. A consecutive sample of patients (> 18 and < 80 years) admitted to public hospitals in selected regions within each participating country with an acute ST elevation myocardial infarction (MI), Non-ST elevation MI, acute myocardial ischaemia or for elective revascularisation was identified retrospectively from medical record systems. Patients were invited to attend a clinical visit with trained research assistants at least 6 months but not more than 2 years after their event. The assessment included self-reported smoking status validated with an expired breath carbon monoxide measurement, self-reported participation in physical activity using the Godin validated questionnaire and standardised measurements of height, weight, blood pressure, blood lipids and blood glucose including an oral glucose tolerance test. 4548 (21.1% women) patients attended the clinical visit. 12.6% were smoking with wide variation across countries (1.9 – 27.3%). 48% of those who were smoking at the time of hospital admission had continued to smoke. 66.5% reported being sedentary with wide variation across countries (51.3 – 90.5%). 24% were obese and 40% centrally obese with a large difference between men (32.3%) and women (69.4%). 38% achieved a blood pressure target of < 130/80 mmHg, 19.2% achieved an LDL-C target of < 1.4 mmol/l and in patients with self-reported diabetes 56% achieved a target HbA1c of < 53 mmol/mol (7%). In those who did not report having diabetes, a further 9.8% had undetected diabetes and 26.9% impaired glucose tolerance. 48% were prescribed all four classes of cardioprotective drugs (antiplatelets, beta blockers, ACE/ARB, lipid lowering agents) with wide variation between countries (25% - 75%) and 88.3% were prescribed both antiplatelets and lipid lowering agents. Only 1219 (26.8%) were advised to attend cardiac rehabilitation with wide variation (4.5% to 58.9%) between countries. Overall only 9.0% (men 9.1%, women 9.1%) of all patients attended cardiac rehabilitation. Figure 1 shows the distribution of the INTERASPIRE Guideline Target Score. There is substantial room for improvement in secondary prevention in patients with coronary disease globally. It is of concern that only 9% of patients received cardiac rehabilitation despite it being a Class 1 recommendation in all prevention guidelines with wide variation in advice and uptake between countries.Figure 1

BACKGROUND:Circulating dietary biomarkers are not direct proxies for intake, as the biomarkers reflect not only food and supplement consumption but also nutrient absorption, metabolism, and tissue distribution. Therefore, along with nutrient intake, several other upstream factors can impact dietary biomarker concentrations, including demographic, medical history, and genetic factors. OBJECTIVES:The aim of this study was to explore the dietary and nondietary determinants of circulating levels of vitamins A, C, D, and E among children aged 6 mo-4 y. METHODS:Plasma retinol, β-carotene, ascorbic acid, 25(OH)D, α-tocopherol, and γ-tocopherol were measured in 2887 samples from 1490 children enrolled in The Environmental Determinants of Diabetes in the Young study. Dietary intake was assessed with 3-d food records. Associations of genetic and environmental factors with biomarker concentrations were examined using multivariable linear regression models with random intercepts. RESULTS:All biomarkers except retinol were positively associated with intake of the same nutrient. Inverse associations were identified between recent gastrointestinal infection and β-carotene, ascorbic acid, and α-tocopherol, whereas recent respiratory infection was associated inversely with plasma retinol. Several genetic determinants of biomarker status were identified, validating previously reported findings. For some genetic and environmental exposures, we found evidence of statistical interaction with same-nutrient intake, indicating that the association between intake and biomarker concentration is dependent on the level or status of these other exposures. For example, the association between β-carotene intake and concentration is weaker among children with a recent respiratory infection. CONCLUSIONS:Our findings suggest that nondietary exposures including childhood infections can alter micronutrient metabolism. This summary of micronutrient determinants will facilitate improved design of future analyses exploring the role of diet in childhood chronic disease etiology through a better understanding of relevant potential confounders and mediators of the diet-outcome relationships.

Purpose The aim was to study the association between dietary intake of B vitamins in childhood and the risk of islet autoimmunity (IA) and progression to type 1 diabetes (T1D) by the age of 10 years. Methods We followed 8500 T1D-susceptible children born in the U.S., Finland, Sweden, and Germany in 2004 -2010 from the Environmental Determinants of Diabetes in the Young (TEDDY) study, which is a prospective observational birth cohort. Dietary intake of seven B vitamins was calculated from foods and dietary supplements based on 24-h recall at 3 months and 3-day food records collected regularly from 6 months to 10 years of age. Cox proportional hazard models were adjusted for energy, HLA-genotype, first-degree relative with T1D, sex, and country. Results A total of 778 (9.2) children developed at least one autoantibody (any IA), and 335 (3.9%) developed multiple autoantibodies. 280 (3.3%) children had IAA and 319 (3.8%) GADA as the first autoantibody. 344 (44%) children with IA progressed to T1D. We observed that higher intake of niacin was associated with a decreased risk of developing multiple autoantibodies (HR 0.95; 95% CI 0.92, 0.98) per 1 mg/1000 kcal in niacin intake. Higher intake of pyridoxine (HR 0.66; 95% CI 0.46, 0.96) and vitamin B12 (HR 0.87; 95% CI 0.77, 0.97) was associated with a decreased risk of IAA-first autoimmunity. Higher intake of riboflavin (HR 1.38; 95% CI 1.05, 1.80) was associated with an increased risk of GADA-first autoimmunity. There were no associations between any of the B vitamins and the outcomes “any IA” and progression from IA to T1D. Conclusion In this multinational, prospective birth cohort of children with genetic susceptibility to T1D, we observed some direct and inverse associations between different B vitamins and risk of IA.