“We’re not talking about a simple chuckle,” he said, “but real mirthful laughter,” which, he added, should last for at least 15 seconds. Laughter, he explained, might exert its beneficial effect through the release of endorphins by the brain, which activate receptors on the endothelium which in turn lead to the release of nitric oxide. “Nitric oxide dilates blood vessels, reduces inflammation, cholesterol deposition and clotting,” said Miller.

Listening to music with faster tempos results in increased breathing, heart rate and blood pressure, while slower music caused declines in heart rates, according to another study² cited by the organisation. Dr Hans-Joachim Trappe, an organist and cardiologist from the University of Bochum, Herne, Germany, believes that classical music offers the ideal therapy for patients with hypertension and increased heart rates. He is now  planning a prospective study – “Bach or beta blockers” – in which patients with hypertension will be randomised to one or the other and followed with continuous blood pressure monitoring.

The ESC asserts that, despite a recent declaration on the prevention and control of CVD from the United Nations, efforts to lower the burden of CVD cannot rest only with policy makers and global leaders. Individuals must learn about the risk factors and take steps to reduce their own and their family’s liability, the Society insists.

References

1 Miller M. Laughter and vascular function. ESC Congress 2011, Programme number 351.

2 Trappe H-J. Music and health: clinical implications. ESC Congress 2011, Programme number 352.

World Heart Day was also recognised by the Members of the European Parliament (MEP) Heart Group, whose secretariat is managed by the European Heart Network and European Society of Cardiology (ESC).  The ESC asserts that children can influence their parents as much as vice versa within the home, citing a study¹ from this year’s ESC Congress, led by Dr Luciana Fornari (University of Sao Paulo, Brazil).

The study divided 197 school children and 323 parents into  a control group, provided with basic educational material on CVD prevention at the start and middle of the academic year, and an active group also exposed to weekly educational sessions run by a multidisciplinary team of nurses, PE teachers, physiotherapists, nutritionists and psychologists.

When the study started a similar number of parents in each group were assessed as having a greater than 10% risk of developing CVD over the next 10 years. However, after one year just one parent in the intervention group compared to 13 in the control group were estimated to have a greater than 10% risk of developing CVD over the next 10 years. These results represented a 91% risk reduction in the intervention group, compared to a 13% reduction in the control group.

References

1 Fornari L. Children first: how an educational program in cardiovascular prevention at school can improve parent’s cardiovascular risk. ESC Congress 2011, Programme number 5314.

Speaking at the Summit, Lord Howe said:

“It is within our gift to do something about these clots, to reduce the suffering of thousands of people and to save a great many lives. The NHS has made a tremendous start in improving this, and those making the biggest difference are those on the front-line – the junior doctors, nurses, pharmacists and GPs – who can work together to prevent needless suffering of patients.”

“Their progress is a reflection of what we want to achieve across the NHS – clinical leadership and transparency.
The need to do better was first recognised by the previous Chief Medical Officer, Sir Liam Donaldson, and NHS leaders some years ago, and since then we have pioneered a system where hospitals report how many patients have been risk assessed and locally decide whether the appropriate prevention measures are in place. The results are collated and published on a quarterly, soon to be monthly, basis – this level of transparency on how a service deals with the risk of clots is unparalleled across the globe.

“The aim of the system is to see that every patient admitted to hospital has had a risk assessment and appropriate prevention. While the NHS still has some work to do to achieve this, the initial results are impressive – the numbers of hospitals achieving the target of 90 per cent of patients assessed virtually trebled between July and December, from 18 to 53. The NHS in England is the only health system in the world to implement such a comprehensive system at a national level.”

Sir Bruce Keogh, NHS Medical Director, who has led the development of the new system, said:

“All of us working in the NHS have a moral, professional and social responsibility to address a longstanding issue of this magnitude which puts patients at unnecessary risk of avoidable death, long-term disability and chronic ill health. It is clearly the right thing to do. That is why all professions, clinical and managerial, agreed to make this the number one clinical priority for the NHS last year and why we have made such remarkable progress in such a short period of time.”

Chair of the All-Party Parliamentary Thrombosis Group, Andrew Gwynne MP said:

“The scale and cost of avoidable hospital acquired VTE – financially and in terms of long-term disability and lives lost – is staggering.
The APPTG is delighted to be hosting this summit. The APPTG will continue to work with NHS decision makers and clinicians to ensure effective use of the best practice and policy now available to the NHS. We hope that any opportunities presented by the new NHS structure will be used to deliver a reduction in the incidence of VTE, and a legacy of quality VTE prevention in patient care that we can be proud of.”

“Within the ESC we accept NICE as one of the main sources of reference for clinical decision making in cardiology,” says ESC spokesman Joep Perk, from Linnaeus University (Sweden). “Currently even if individuals try to eat healthy diets there are issues out of their control, such as the salt content in bread, that have an adverse effect on their cardiovascular health. This document details the legislative changes that could be introduced to protect them.”

The NICE guidance, which focuses mainly on food production and its influence on the nation’s diet, aims to change the cardiovascular risk factors faced by the UK population through regulation, legislation, subsidy and taxation or by rearranging the physical layout of communities. Previously the UK has focused on individual interventions, an approach which identifies and treats people at higher risk. Physical inactivity, smoking and excessive alcohol consumption are also covered to a lesser extent in the NICE document.

Simon Capewell, an ESC spokesperson from the University of Liverpool (UK), who is also Vice Chair of the NICE Guidance Development Group, says, “There was a feeling that dietary interventions have been largely neglected, yet have a big potential to deliver CVD benefits. The guidance shows how by introducing simple changes at the population level huge gains could be made in reducing the death toll from cardiovascular disease. This is no longer an optional discussion, but an issue that governments and the rest of society have to confront.”

The intention of the document, says Capewell, is to get the evidence for change firmly into the public arena “The idea is to kick start a debate, and persuade politicians to set both short term and long term goals for change,” he says.

Key evidence outlined in the NICE document includes:

Reducing mean salt intakes by 3 g per day for adults (to achieve a target of 6 g daily) would in the UK lead to around 14–20,000 fewer annual deaths from CVD each year. Reducing salt added during the manufacturing process is considered especially important since this is estimated to represent 70 to 90% of the population’s total salt intake.

Evidence suggests that reducing saturated fat intakes from 14% to 7 % of energy intake (to reach the levels seen in Japan) might prevent up to 30,000 CVD deaths annually.

If industrially-produced trans fats were banned (as successfully done in Denmark) would 4,500 and 7000 lives might be saved annually.

The guidance also considers the evidence for wider policy actions, such as extending restrictions on TV advertising for foods high in saturated fats, salt and sugar, making healthy food alternatives cheaper than junk food, establishing traffic light food labelling systems and giving local authorities powers to limit fast food outlets. The document places particular emphasis on the importance of taking action to prevent the elevation of CVD risk factors among children. “It’s well known that CVD commences in child-hood, making this aspect of the report of vital importance for future generations,” says Perk.

The NICE document indicates how introducing such changes would rapidly become self financing. Reducing population cardiovascular risk by even 1% would generate discounted savings of approximately £260 million per year. The good news, adds Capewell, is that introducing such changes can deliver rapid results. 
“In Eastern Europe when food subsidies for animal fats were abolished in the 1990s death rates from CVD dropped by one quarter within five years,” he says.

“You have only to look at the recent tobacco battles – where banning smoking in public places rapidly decreased the amount of acute coronary syndromes by 17% – to take inspiration and see how enormously effective political action can be,” says Rydén.

For maximum impact, adds Rydén, CVD needs to be tackled at both the European wide level and on an individual country basis. “Ideally each European country needs to bespoke the NICE evidence to their own situation, but the fact that few other European countries have NICE type organisations may make the process problematic,” he says.

“This study provides excellent ammunition both to convince patients about the benefits of reducing their individual salt intakes and also to persuade the EU of the urgent need to introduce legislation to restrict the salt content of  processed foods,” said ESC spokesman Professor Frank Ruschitzka, a cardiologist and hypertension specialist from the University of Zurich, Switzerland.

“This study represents the evidence that a reduction of salt intake not only lowers blood pressure but also prevents cardiovascular events. The case for population-wide salt reduction is now compelling,” he added.

In the paper, Kirsten Bibbins-Domingo and colleagues, from the University of California, San Francisco, USA, undertook a computer simulation showing the effects of population wide reductions of dietary salt intakes in all adults aged 35 to 85 years in the USA.   Reducing  dietary salt intake by 3 g per day (1200mg less sodium per day) could result in 60,000 to 120,000 fewer cases of heart disease , 32,000 to 66,000 fewer strokes and 54,000 to 100,000  fewer heart attacks.

A reduction in dietary salt of 3g per day, the authors went on to say, would have approximately the same effect on reducing cardiac events as a 50 % reduction in tobacco use, a 5% reduction in body mass index among obese adults or the use of statins to treat people at low or intermediate risk for CHD events.  Furthermore, reducing dietary salt intakes by 3g per day would save  $10 billion to $ 24 billion in annual health care costs.

ESC spokesperson Professor Giuseppe Mancia,  from the University of Milano-Bicocca, St. Gerardo Hospital (Milan, Italy), said the annual health cost savings outlined in the study would be likely to prove a persuasive argument for both the EU and individual European governments.

Recent studies clearly show that salt reduction reduces cardiovascular deaths.⁴ Epidemiological studies have also firmly established that increased intakes of salt directly increase blood pressure.  High salt intakes are believed to exert their detrimental effects by influencing fluid retention, which in turn increases blood pressure. “But it’s important for patients to appreciate that not all cardiovascular problems relating to salt are mediated through hypertension. Salt can have an adverse effect on cardiovascular health, even among people with normal blood pressure,” said Ruschitzka.

Salt intakes across Europe are known to vary widely, ranging from 8.6 g of salt per day  in the UK, to around 12 g salt in Croatia. Even the best intakes, however, are falling  widely short of the  ESC Clinical Practice Guidelines for the Management of Arterial Hypertension (2) , based on WHO data, that recommend that only 5g of salt should be consumed  per day. This amounts to just one teaspoonful.

While individuals may use salt sparingly at home, around 75 % of the salt we eat is already in the food we buy. This, says the ESC, underlines the need for legislation to lay down guidelines. “The reality of international food production in Europe means that such public health initiatives need to be tackled on a European wide basis, rather than an individual country basis,” said Ruschitzka.

Furthermore, added Mancia, concerted action is usually more effective. “It has the advantage of preventing country to country inequalities and furthermore prevents the reinvention of the wheel in each individual country,” he said.

But calls for legislation do not mean that physicians should stop their efforts to  persuade patients to introduce individual changes in lifestyle. Patients, they stress, need to be taught about the importance of reducing salt in their cooking and also for the need to check food labels. People need to learn to appreciate that the salt contents can vary widely even in the same product. Take bread, for example. Recent research from Consensus Action on Salt and Health (CASH, a charity lobbying food manufacturers in the UK) has shown that the highest salt content was 3g salt per 100 g of bread, while the lowest was 0.7 g salt per 100g.

To improve cardiovascular health, salt reduction cannot be undertaken in isolation. “It needs to be remembered that lifestyle measures such as smoking cessation, weight reduction, increased physical exercise, and eating plenty of fruit and vegetables are also important for reducing cardiovascular disease,” said Mancia.

Salt was again on the agenda with World Salt Awareness Week 2010 , (February 1- 7) (3).  The week was run by World Action on Salt and Health (WASH), a global group that works with governments  to highlight the need for widespread introduction of population based salt reduction strategies.

Much can be done to reduce salt intakes through public health policy, say WASH.  They cite the success of Consensus Action on Salt and Health (CASH),  launched in 1996 to encourage  food manufacturing companies in the UK to make voluntary reductions in their  salt content. Since the start of the policy salt intakes among UK adults (calculated from 24-hour urine samples) have fallen from 9.5 to 8.6 g per day.

In July 2009, WASH surveyed over 260 food products available around the world from food manufacturers such as KFC, McDonalds, Kellogg’s, Nestle, Burger King and Subway, finding surprisingly wide spread variations. For example, Kellogg’s All Bran for sale in France, Norway, Sweden and the Netherlands contains 1.30 g salt per 100 g compared to salt levels of 0.65 g per 100g for the product in the US. Such data underlines the urgent need to eradicate country to country inequalities, and bring everyone up to the highest possible standards.

“The paper by Bibbins-Domingo and colleagues is an urgent call to action. Policy makers in the European Community need to implement public health interventions that result in reductions in salt intake now. Reducing the salt content of our unneccesarily oversalted ,processed food is an inexpensive, yet highly effective public health intervention that we can’t afford to miss,“ concluded Ruschitzka.

References

1. Bibbins-Domingo K, Glenn CC, Coxson PG et al. Projected Effect of Dietary Salt Reductions on Future Cardiovascular Disease.  New Engl J Med. 2010 published on line on 20 January 2010 (10.1056/NEJMoa0907355)
2. http://www.escardio.org/guidelines-surveys/esc-guidelines/Pages/arterial-hypertension.aspx
3. www.worldactiononsalt.com
4. Pasquale Strazzullo, Lanfranco D’Elia, Ngianga-Bakwin Kandala, and Francesco P Cappuccio.  Salt intake, stroke, and cardiovascular disease: meta-analysis of prospective studies. BMJ 2009;339:b4567, doi: 10.1136/bmj.b4567 (Published 24 November 2009)

Dr Rachel Huxley, of The George Institute for International Health, University of Sydney, Australia, and colleagues identified 18 studies involving 457,922 participants and assessing the association between coffee consumption and diabetes risk published between 1966 and 2009. Six 
studies involving 225,516 individuals also included information about decaffeinated coffee, whereas seven studies with 286,701 participants reported on tea consumption.

When the authors combined and analyzed the data, they found that each additional cup of coffee consumed in a day was associated with a 7 percent reduction in the excess risk of diabetes.

Individuals who drank three to four cups per day had an approximately 25 percent lower risk than those who drank between zero and two cups per day.

In addition, in the studies that assessed decaffeinated coffee consumption, those who drank more than three to four cups per day had about a one-third lower risk of diabetes than those who drank none. Those who drank more than three to four cups of tea had a one-fifth lower risk than those who drank no tea.

That the apparent protective effect of tea and coffee consumption appears to be independent of a number of potential confounding variables raises the possibility of direct biological effects, the authors write. Because of the association between decaffeinated coffee and diabetes risk, the association is unlikely to be solely related to caffeine. Other compounds in coffee and tea including magnesium, antioxidants known as lignans or chlorogenic acids may be involved, the authors note.
 
If such beneficial effects were observed in interventional trials to be real, the implications for the millions of individuals who have diabetes mellitus, or who are at future risk of developing it, would be substantial, they conclude. For example, the identification of the active components of these beverages could open up new therapeutic options for the primary prevention of diabetes mellitus.

The findings also pose the question of whether patients most at risk for diabetes mellitus may in the future be advised to increase their consumption of tea and coffee in addition to increasing their levels of physical activity. 
Spokesperson for the European Society of Cardiology, Professor Lars Rydén (Sweden), who is a diabetes specialist had the following advice:

“This is a cautiously and carefully conducted meta-analysis which means authors have carefully conducted studies although each are too small to give an answer to the question although they indicate a positive correlation between the consumption of coffee and a decreasing occurrence of diabetes. So the principle is that if you drink coffee whether it is decaffeinated or not, you have less chance of developing diabetes. The data has been strengthened by bringing several studies together. There are sometimes claims that coffee may do harm, that it may increase the propensity to Cardiovascular disease, but there is no evidence for this. The message is that people may drink coffee safely. Coffee from this point of view may actually be of benefit, as well as reducing the risk of getting diabetes – although the reduction is small (around 7%).”

However Prof Rydén warns that lifestyle changes far outweigh a regular coffee intake. 

“Coffee helps, but other things are even more important. Those who are overweight should reduce their bodyweight by 5-10% – not too much – and include physical activity such as a brisk walk for 30 minutes a day. Then those people who are at risk of developing diabetes will reduce this risk by 40-50%. 

It is interesting to consider why a beverage like coffee has a beneficial effect. It is obviously not the caffeine as decaffeinated coffee has the same efficiency as caffeinated coffee. Coffee may contain antioxidants but the studies have not measured the number of chemicals in the blood which is important.”

NOTES

Dr. Huxley is supported by a Career Development Award from the National Heart Foundation of Australia. This work was additionally supported by a grant from the National Health and Medical Research Council of Australia; a Research Career Development Fellowship from the UK Wellcome Trust; and a research grant from Institut Servier, France and Assistance Publique-Hopitaux de Paris.

References:

1. Arch Intern Med. 2009;169[22]:2053-2063