Pediatric Cardiology

, Volume 38, Issue 5, pp 965–973 | Cite as

Red Flags for Maltese Adults with Congenital Heart Disease: Poorer Dental Care and Less Sports Participation Compared to Other European Patients—An APPROACH-IS Substudy

  • Maryanne Caruana
  • Silke Apers
  • Adrienne H. Kovacs
  • Koen Luyckx
  • Corina Thomet
  • Werner Budts
  • Maayke Sluman
  • Katrine Eriksen
  • Mikael Dellborg
  • Malin Berghammer
  • Bengt Johansson
  • Alexandra Soufi
  • Edward Callus
  • Philip Moons
  • Victor Grech
  • On behalf of the APPROACH-IS consortium and the International Society for Adult Congenital Heart Disease (ISACHD)
Original Article


Studies in recent years have explored lifestyle habits and health-risk behaviours in adult congenital heart disease (ACHD) patients when compared to controls. The aim of this study was to investigate differences in lifestyle habits between Maltese and other European ACHD patients. Data on alcohol consumption, cigarette smoking, substance misuse, dental care and physical activity collected in 2013–2015 during “Assessment of Patterns of Patient-Reported Outcomes in Adults with Congenital Heart disease-International Study” (APPROACH-IS) were analysed. Responses from 119 Maltese participants were compared to those of 1616 participants from Belgium, France, Italy, Norway, Sweden, Switzerland and the Netherlands. Significantly fewer Maltese patients with simple (Maltese 84.1% vs. European 97.5%, p < 0.001) and moderately complex CHD (Maltese 83.6% vs. European 97.4%, p < 0.001) brushed their teeth daily. Only 67.2% of Maltese with moderately complex disease had dental reviews in the previous year compared to 80.3% of Europeans (p = 0.02). Maltese patients with simple (Maltese 31.8% vs. European 56.1%, p = 0.002) and moderately complex lesions (Maltese 30.0% vs. European 59.2%, p < 0.001) performed less regular sport activities. Comparison by country showed Maltese patients to have significantly poorer tooth brushing and sports participation than patients from any other participating country. Alcohol consumption, cigarette smoking and substance misuse were not significantly different. This study highlights lifestyle aspects that Maltese ACHD patients need to improve on, which might not be evident upon comparing patients to non-CHD controls. These findings should also caution researchers against considering behaviours among patients in one country as necessarily representative of patients on the larger scale.


Congenital heart disease Health behaviour Lifestyle Risk factors 



The authors would like to thank Dr. Sandra Distefano (Consultant in Public Health Medicine, Directorate for Health Information and Research) for providing national statistics on infective endocarditis. APPROACH-IS consortium: Luis Alday, Héctor Maisuls, Betina Vega (Córdoba, Argentina, Hospital de Niños); Samuel Menahem, Sarah Eaton, Ruth Larion, Qi Feng Wang (Melbourne, Australia, Monash Medical Center); Werner Budts, Kristien Van Deyk (Leuven, Belgium, University Hospitals of Leuven); Silke Apers, Eva Goossens, Jessica Rassart, Koen Luyckx, Philip Moons (Leuven, Belgium, University of Leuven); Gwen Rempel, Andrew Mackie, Ross Ballantyne, Kathryn Rankin, Colleen Norris, Dylan Taylor, Isabelle Vondermuhll, Jonathan Windram, Pamela Heggie, Gerri Lasiuk (Edmonton, Canada, University of Alberta); Paul Khairy, Anna Proietti, Annie Dore, Lise-Andrée Mercier, François-Pierre Mongeon, François Marcotte, Reda Ibrahim, Blandine Mondésert, Marie-Claude Côté (Montreal, Canada, Montreal Heart Institute); Adrienne Kovacs, Erwin Oechslin, Mimi Bandyopadhyay (Toronto, Canada, University Health Network); Alexandra Soufi, Sylvie Di Filippo, François Sassolas, André Bozio (Lyon, France, Hospital Louis Pradel); Shanthi Chidambarathanu, Farida Farzana, Nitya Lakshmi (Chennai, India, Frontier Lifeline Hospital, Dr. K. M. Cherian Heart Foundation); Edward Callus, Emilia Quadri, Massimo Chessa, Giovanna Campioni, Alessandro Giamberti (Milan, Italy, IRCCS Policlinco San Donato Hospital); Junko Enomoto, Yoshiko Mizuno (Chiba, Japan, Chiba Cardiovascular Center); Maryanne Caruana, Victor Grech, Sheena Vella, Anabel Mifsud, Neville Borg, Daniel Chircop, Matthew Mercieca Balbi, Rachel Vella Critien, James Farrugia, Yanika Gatt, Darlene Muscat (Msida, Malta, Mater Dei Hospital); Katrine Eriksen, Mette-Elise Estensen (Oslo, Norway, Oslo University Hospital); Mikael Dellborg, Malin Berghammer (Gothenburg, Sweden, Sahlgrenska University Hospital); Eva Mattson, Anita Strandberg, Pia Karlström-Hallberg (Stockholm, Sweden, Karolinska University Hospital); Bengt Johansson, Anna-Karin Kronhamn (Umeå, Sweden, University Hospital of Umeå); Markus Schwerzmann, Corina Thomet, Margrit Huber (Bern, Switzerland, University Hospital Bern); Jou-Kou Wang, Chun-Wei Lu, Hsiao-Ling Yang, Yu Chuan Hua (Taipei, Taiwan, National Taiwan University Hospital); Barbara Mulder, Maayke Sluman (Amsterdam, the Netherlands, Amsterdam Medical Center); Marco Post (Nieuwegein, the Netherlands, St. Antonius Hospital); Els Pieper (Groningen, the Netherlands, University Medical Center Groningen); Kathinka Peels (Eindhoven, the Netherlands, Catharina Hospital); Marc Waskowsky (Zwolle, the Netherlands, Isala Clinic); Gruschen Veldtman, Michelle Faust, Colin Lozier, Christy Reed, Jamie Hilfer (Cincinnati, USA, Cincinnati Children’s Hospital Medical Center); Curt Daniels, Jamie Jackson (Columbus, USA, Nationwide Children’s Hospital); Shelby Kutty, Carolyn Chamberlain (Omaha, USA, Children’s Hospital & Medical Center); Stephen Cook, Morgan Hindes (Pittsburgh, USA, Children’s Hospital of Pittsburgh of UPMC); Ari Cedars, Kamila White (Saint Louis, USA, Washington University and Barnes Jewish Heart & Vascular Center, University of Missouri); Anitra Rompfh, Susan Fernandes, Kirstie MacMillen (Palo Alto, USA, Stanford University).


The APPROACH-IS project was supported by the Research Fund—KU Leuven (Leuven, Belgium) through grant OT/11/033; by the Swedish Heart–Lung Foundation (Sweden) through Grant No. 20130607; and by the University of Gothenburg Centre for Person-centred Care (Gothenburg, Sweden). In Malta, the work was supported financially by A.M. Mangion Ltd. (Luqa, Malta), Technoline Ltd. (Gzira, Malta) and Cherubino Ltd. (Gzira, Malta) which together covered the costs of printing and posting of the questionnaires.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committees of the participating centres and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Moons P, Bovijn L, Budts W, Belmans A, Gewillig M (2010) Temporal trends in survival to adulthood among patients born with congenital heart disease from 1970 to 1992 in Belgium. Circulation 122(22):2264–2272CrossRefPubMedGoogle Scholar
  2. 2.
    Pilapil M, DeLaet D (2015) Health risk behaviors in adolescents and young adults with special health care needs. Curr Opin Pediatr 27(1):132–137CrossRefPubMedGoogle Scholar
  3. 3.
    Roche SL, Silversides CK (2013) Hypertension, obesity, and coronary artery disease in the survivors of congenital heart disease. Can J Cardiol 29(7):841–848CrossRefPubMedGoogle Scholar
  4. 4.
    Zomer AC, Vaartjes I, Uiterwaal CS, van der Velde ET, Sieswerda GJ, Wajon EM et al (2012) Social burden and lifestyle in adults with congenital heart disease. Am J Cardiol 109(11):1657–1663CrossRefPubMedGoogle Scholar
  5. 5.
    Moons P, Van Deyk K, Dedroog D, Troost E, Budts W (2006) Prevalence of cardiovascular risk factors in adults with congenital heart disease. Eur J Cardiovasc Prev Rehabil 13(4):612–616CrossRefPubMedGoogle Scholar
  6. 6.
    Sandberg C, Pomeroy J, Thilen U, Gradmark A, Wadell K, Johansson B (2016) Habitual physical activity in adults with congenital heart disease compared with age- and sex-matched controls. Can J Cardiol 32(4):547–553CrossRefPubMedGoogle Scholar
  7. 7.
    Janssens A, Goossens E, Luyckx K, Budts W, Gewillig M, Moons P (2016) Exploring the relationship between disease-related knowledge and health risk behaviours in young people with congenital heart disease. Eur J Cardiovasc Nurs 15(4):231–240CrossRefPubMedGoogle Scholar
  8. 8.
    Overgaard D, Schrader AM, Lisby KH, King C, Christensen RF, Jensen HF et al (2014) Substance use, dental hygiene, and physical activity in adult patients with single ventricle physiology. Congenit Heart Dis 9(1):75–82CrossRefPubMedGoogle Scholar
  9. 9.
    Caruana M, Grech V (2016) Lifestyle habits among adult congenital heart disease patients in Malta. Congenit Heart Dis 11(4):332–340CrossRefPubMedGoogle Scholar
  10. 10.
    Apers S, Kovacs AH, Luyckx K, Alday L, Berghammer M, Budts W et al (2015) Assessment of patterns of patient-reported outcomes in adults with congenital heart disease—International Study (APPROACH-IS): rationale, design, and methods. Int J Cardiol 179:334–342CrossRefPubMedGoogle Scholar
  11. 11.
    Goossens E, Luyckx K, Mommen N, Gewillig M, Budts W, Zupancic N et al (2013) Health risk behaviors in adolescents and emerging adults with congenital heart disease: psychometric properties of the Health Behavior Scale-Congenital Heart Disease. Eur J Cardiovasc Nurs 12(6):544–557CrossRefPubMedGoogle Scholar
  12. 12.
    Warnes CA, Liberthson R, Danielson GK et al (2001) Task force 1: the changing profile of congenital heart disease in adult life (32nd Bethesda Conference). J Am Coll Cardiol 37(5):1170–1175CrossRefPubMedGoogle Scholar
  13. 13.
    Ladouceur M, Iserin L, Cohen S, Legendre A, Boudjemline Y, Bonnet D (2013) Key issues of daily life in adults with congenital heart disease. Arch Cardiovasc Dis 106(6–7):404–412CrossRefPubMedGoogle Scholar
  14. 14.
    Apers S, Kovacs AH, Luyckx K, Thomet C, Budts W, Enomoto J et al (2016) Quality of life of adults with congenital heart disease in 15 countries: evaluating country-specific characteristics. J Am Coll Cardiol 67(19):2237–2245CrossRefPubMedGoogle Scholar
  15. 15.
    Habib G, Lancellotti P, Antunes MJ, Bongiorni MG, Casalta JP, Del Zotti F, et al (2015) ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J 36(44):3075–3128CrossRefPubMedGoogle Scholar
  16. 16.
    Sothern MS, Loftin M, Suskind RM, Udall JN, Blecker U (1999) The health benefits of physical activity in children and adolescents: implications for chronic disease prevention. Eur J Pediatr 158(4):271–274CrossRefPubMedGoogle Scholar
  17. 17.
    King AC, Taylor CB, Haskell WL, DeBusk RF (1989) Influence of regular aerobic exercise on psychological health: a randomized, controlled trial of healthy middle-aged adults. Health Psychol 8(3):305–324CrossRefPubMedGoogle Scholar
  18. 18.
    Ekelund U, Anderssen S, Andersen LB, Riddoch CJ, Sardinha LB, Luan J et al (2009) Prevalence and correlates of the metabolic syndrome in a population-based sample of European youth. Am J Clin Nutr 89(1):90–96CrossRefPubMedGoogle Scholar
  19. 19.
    Neinstein LS, Irwin CE Jr (2013) Young adults remain worse off than adolescents. J Adolesc Health 53(5):559–561CrossRefPubMedGoogle Scholar
  20. 20.
    Longmuir PE, Brothers JA, de Ferranti SD, Hayman LL, Van Hare GF, Matherne GP et al (2013) Promotion of physical activity for children and adults with congenital heart disease: a scientific statement from the American Heart Association. Circulation 127(21):2147–2159CrossRefPubMedGoogle Scholar
  21. 21.
    Oja P (2003) Development of a common instrument for physical activity. In: Nosikov A, Gudex C (eds) EUROHIS—developing common instruments for health surveys. IOS Press, Amsterdam, pp 87–88Google Scholar
  22. 22.
    Grech V, Aquilina S, Camilleri E, Camilleri K, Busuttil ML, Sant’Angelo VF, Calleja N (2016) The Malta Childhood National Body Mass Index Study—A Population Study. J Pediatr Gastroenterol Nutr doi: 10.1097/MPG.0000000000001430 PubMedGoogle Scholar
  23. 23.
    Moons P, De Volder E, Budts W, De Geest S, Elen J, Waeytens K et al (2001) What do adult patients with congenital heart disease know about their disease, treatment, and prevention of complications? A call for structured patient education. Heart 86(1):74–80CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Van Deyk K, Pelgrims E, Troost E, Goossens E, Budts W, Gewillig M et al (2010) Adolescents’ understanding of their congenital heart disease on transfer to adult-focused care. Am J Cardiol 106(12):1803–1807CrossRefPubMedGoogle Scholar
  25. 25.
    Swan L, Hillis WS (2000) Exercise prescription in adults with congenital heart disease: a long way to go. Heart 83(6):685–687CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Reybrouck T, Mertens L (2005) Physical performance and physical activity in grown-up congenital heart disease. Eur J Cardiovasc Prev Rehabil 12(5):498–502CrossRefPubMedGoogle Scholar
  27. 27.
    Budts W, Borjesson M, Chessa M, van Buuren F, Trigo Trindade P, Corrado D et al (2013) Physical activity in adolescents and adults with congenital heart defects: individualized exercise prescription. Eur Heart J 34(47):3669–3674CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  • Maryanne Caruana
    • 1
  • Silke Apers
    • 2
    • 3
  • Adrienne H. Kovacs
    • 4
  • Koen Luyckx
    • 5
  • Corina Thomet
    • 6
  • Werner Budts
    • 7
  • Maayke Sluman
    • 8
  • Katrine Eriksen
    • 9
  • Mikael Dellborg
    • 10
    • 11
  • Malin Berghammer
    • 12
    • 13
  • Bengt Johansson
    • 14
  • Alexandra Soufi
    • 15
  • Edward Callus
    • 16
  • Philip Moons
    • 2
    • 10
  • Victor Grech
    • 17
  • On behalf of the APPROACH-IS consortium and the International Society for Adult Congenital Heart Disease (ISACHD)
  1. 1.Department of CardiologyMater Dei HospitalMsidaMalta
  2. 2.Department of Public Health and Primary CareKU Leuven - University of LeuvenLeuvenBelgium
  3. 3.Department of Development and RegenerationKU Leuven - University of LeuvenLeuvenBelgium
  4. 4.Knight Cardiovascular InstituteOregon Health & Science UniversityPortlandUSA
  5. 5.School Psychology and Child and Adolescent DevelopmentKU Leuven - University of LeuvenLeuvenBelgium
  6. 6.Center for Congenital Heart DiseaseUniversity Hospital BernBernSwitzerland
  7. 7.Division of Congenital and Structural Cardiology, University Hospitals LeuvenKU Leuven - University of LeuvenLeuvenBelgium
  8. 8.Department of CardiologyAcademic Medical CenterAmsterdamThe Netherlands
  9. 9.Oslo University Hospital, RikshospitaletOsloNorway
  10. 10.Institute of MedicineThe Sahlgrenska Academy at University of GothenburgGothenburgSweden
  11. 11.Adult congenital heart unit, Sahlgrenska University Hospital/Östra and Institute for MedicineThe Sahlgrenska Academy at University of GothenburgGothenburgSweden
  12. 12.Department of Health ScienceUniversity WestTrollhättanSweden
  13. 13.Centre for Person-Centred Care (GPCC)University of GothenburgGothenburgSweden
  14. 14.Department of Clinical Medicine and Public HealthUmeå UniversityUmeåSweden
  15. 15.Hospital Louis PradelLyonFrance
  16. 16.Clinical Psychology UnitIRCCS Policlinico San DonatoSan Donato MilaneseItaly
  17. 17.Department of PaediatricsUniversity of Malta Medical SchoolMsidaMalta

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