LAUSR

Prevention starts with lifestyle changes—most importantly, moving away from a sedentary lifestyle, as physical activity is associated with increased longevity and decreased cardiovascular risk. The majority of the population is still sedentary. How much exercise is appropriate is an issue, as too much of a good thing may be damaging. These issues are discussed in the first review article entitled ‘Personalized exercise dose prescription’, by Petra Zubin Maslov and colleagues from the Icahn School of Medicine at Mount Sinai, New York, NY, USA. In order to maximize the health benefits of physical activity, health care practitioners should be familiarized with the most appropriate dose of exercise for each individual, depending on their habitual physical activity and relative fitness. Here they describe the lowest and highest level of exercise that proves beneficial in terms of health and what should hypothetically be considered ‘the sweet spot’. While lifestyle changes are the first step, drugs are equally important in prevention. However, patient compliance with prescribed drug therapy is often poor, but is particularly important after acute coronary syndrome (ACS). Hanne Winther Frederiksen, from the Medizinische Klinik Universitätsklinikum in Würzburg, Germany, addressed this in her clinical research article ‘Differences in initiation and discontinuation of preventive medications and use of non-pharmacological interventions after acute coronary syndrome among migrants and Danish-born’. The authors selected 33 199 individuals from nationwide registries and followed them for 180 days after ACS. Non-Western migrants had lower relative risks for initiating adenosine diphosphate (ADP) and angiotensin-converting enzyme (ACE) inhibitors and patient education and greater hazards for discontinuing statins, ADP inhibitors, b-blockers and ACE inhibitors and fewer contacts for physical exercise and patient education. Thus huge differences between non-Western migrants and Danish-born individuals in initiation and discontinuation of preventive medications and the use of nonpharmacological interventions after ACS exist and cannot be explained by differences in comorbidity or sociodemographic factors. These novel findings are further discussed in an editorial by Gregory Y. H. Lip from the City Hospital Birmingham, Birmingham, UK. An important target of prevention is diabetes. Although weight reduction works, it is often difficult to achieve, and medication becomes necessary to control blood sugar. In their review ‘Cardioprotective anti-hyperglycaemic medications: a review of clinical trials’, Haitham M. Ahmed and colleagues from the Cleveland Clinic, Cleveland, OH, USA note that despite extensive efforts, cardiovascular disease remains the leading cause of death among diabetics. Recently, sodium-glucose cotransporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 receptor (GLP-1) agonists have been shown to reduce cardiovascular mortality in four randomized controlled trials. In light of this, the US Food and Drug Administration has approved empagliflozin for cardiovascular mortality reduction in type 2 diabetics. The effects of novel antihyperglycaemic medications is reviewed, as is their mode of action and cardioprotective pathways. There is a paucity of data on the influence of diabetes on longterm outcomes after ischaemic stroke. In their article ‘Diabetes and long-term outcomes of ischaemic stroke: findings from Get With The Guidelines–Stroke’, Gregg C. Fonarow and colleagues from the UCLA Division of Cardiology, Los Angeles, CA, USA assessed this in 409 060 patients with and without diabetes. The 29.6% of patients with diabetes were younger, had more comorbidities and a higher risk of all-cause mortality and all-cause readmission, a higher composite of mortality and all-cause readmission and a higher composite of mortality and cardiovascular readmission as well as higher heart failure readmission and non-stroke readmission. Thus, among older ischaemic stroke patients, diabetes was associated with increased risks of death, cardiovascular and non-cardiovascular hospitalizations, heart failure and stroke recurrence. These findings are put into further context in an editorial by Francesco Cosentino from the University Hospital Solna, Stockholm, Sweden. Besides classical risk factors that are part of the ESC Guideline recommendations, novel risk factors have been identified. Bacteria in our gastrointestinal tract eat what we eat and their end products are