Physicians’ perception, knowledge and awareness of cardiovascular risk factors and adherence to prevention guidelines: The PERCRO-DOC survey

The secondary prevention of coronary heart disease in US adults 75 Years and older in daily practice: Results from the National Health and Nutrition Examination Survey 1999-2018 survey

Background

Pharmacologic therapies, risk factor control, and lifestyle alterations were independently proven to reduce long-term cardiovascular events. However, comprehensive research examining the extent to which individuals aged 75 and above in the United States adhere to national guidelines for the secondary prevention of coronary heart disease is limited. Therefore, the primary objective of this study was to examine the current state of secondary prevention of coronary heart disease in persons 75 years of age and older in the United States and to examine the factors that contribute to inadequate drug utilization and poor control of numerous risk factors.

Methods

We identified patients over 75 years of age with coronary heart disease based on the National Health and Nutrition Examination Survey from 1999 to 2018 and analyzed the adequacy of risk factor control and adherence to lifestyle and medication recommendations to assess the effectiveness of coronary heart disease management. Logistic regression analysis was used to identify factors associated with uncontrolled risk factors or noncompliance with recommended medications.

Results

We collected information from 1566 known coronary heart disease patients aged ≥75 years of age. The majority were at target goals for blood pressure (58.88%), low-density lipoprotein cholesterol (66.85%), and glycated hemoglobin (76.12%). Only 27.8% and 36.06% were at targets for body mass index and waist circumference, respectively. 91.95% reported smoking cessation, 85.98% followed recommended alcohol consumption, whereas only 10.34% reported sufficient physical activity. For β blockers, angiotensin -converting enzyme inhibitors/angiotensin receptor blockers, statins, and antiplatelet drugs, the utilization of indicated therapy was 54.41%, 49.36%, 54.79%, and 19.03%, respectively (6.26% for all 4 medications). The results of the logistic regression analysis demonstrated that diabetes mellitus and metabolic syndrome were critical markers of numerous uncontrolled risk variables as well as noncompliance with medication regimens.

Conclusions

A vast majority of coronary heart disease patients ≥75 years in the USA exhibited suboptimal overall control of critical coronary heart disease risk factors. For this patient population, more knowledge is necessary to enable patients to receive continuous support, guidance, and counseling.

Specialty preference for cardiovascular prevention practice in the Southeast US and role of a preventive cardiologist

INTRODUCTION

Cardiovascular disease (CVD) prevention is practiced concurrently by providers from several specialties. Our goal was to understand providers' preference of specialties in CVD prevention practice and the role of preventive cardiologists.

MATERIALS AND METHODS

Between 11 October 2021 and 1 March 2022, we surveyed providers from internal medicine, family medicine, endocrinology, and cardiology specialties to examine their preference of specialties in managing various domains of CVD prevention. We examined categorical variables using Chi square test and continuous variables using t or analysis of variance test.

RESULTS

Of 956 invitees, 263 from 21 health systems and 9 states responded. Majority of respondents were women (54.5%), practicing physicians (72.5%), specializing in cardiology (43.6%), and working at academic centers (51.3%). Respondents favored all specialties to prescribe statins (43.2%), ezetimibe (37.8%), sodium-glucose cotransporter-2 (SGLT2) inhibitors (30.5%), and aspirin in primary prevention (36.3%). Only 7.9% and 9.5% selected cardiologists and preventive cardiologists, respectively, to prescribe SGLT2 inhibitors. Most preferred specialists (i.e. cardiology and endocrinology) to manage advanced lipid disorders, refractory hypertension, and premature coronary heart disease. The most common conditions selected for preventive cardiologists to manage were genetic lipid disorders (17%), cardiovascular risk assessment (15%), dyslipidemia (13%), and refractory/resistant hypertension (12%).

CONCLUSIONS

For CVD prevention practice, providers favored all specialties to manage common conditions, specialists to manage complex conditions, and preventive cardiologists to manage advanced lipid disorders. Cardiologists were least preferred to prescribe SGLT2 inhibitor. Future research should explore reasons for selected CVD prevention practice preferences to optimize care coordination and for effective use of limited expertise.

Clinicians' self-reported efficacy in cardiovascular prevention practice in the southeastern United States

Aim: We assessed self-reported efficacy in cardiovascular prevention practice among internal medicine, family medicine, endocrinology and cardiology clinicians. Patients & methods: We emailed a 21-item questionnaire to 956 physicians, nurse practitioners, physician assistants and pharmacists. Results: 264 clinicians responded (median age: 39 years, 55% women, 47.9% specialists). Most expressed high self-efficacy in lifestyle counselling, prescribing statins, metformin, and aspirin in primary prevention, but low self-efficacy in managing specialized conditions like elevated lipoprotein(a). Compared with specialists, PCPs expressed lower self-efficacy in managing advanced lipid disorders and higher self-efficacy in prescribing sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists. Conclusion: Self-efficacy in cardiovascular prevention varied across specialties. Future research should explore relevant provider, clinic and system level factors to optimize cardiovascular prevention.

Regional differences in physicians' behavior and factors influencing the intensity of PCSK9 inhibitor therapy with alirocumab: a subanalysis of the ODYSSEY APPRISE study

Background

Despite better accessibility of the effective lipid-lowering therapies, only about 20% of patients at very high cardiovascular risk achieve the low-density lipoprotein cholesterol (LDL-C) goals. There is a large disparity between European countries with worse results observed for the Central and Eastern Europe (CEE) patients. One of the main reasons for this ineffectiveness is therapeutic inertia related to the limited access to appropriate therapy and suitable dosage intensity. Thus, we aimed to compare the differences in physicians' therapeutic decisions on alirocumab dose selection, and factors affecting these in CEE countries vs. other countries included in the ODYSSEY APPRISE study.

Methods

ODYSSEY APPRISE was a prospective, single-arm, phase 3b open-label (≥12 weeks to ≤30 months) study with alirocumab. Patients received 75 or 150 mg of alirocumab every 2 weeks, with dose adjustment during the study based on physician's judgment. The CEE group in the study included Czechia, Greece, Hungary, Poland, Romania, Slovakia, and Slovenia, which we compared with the other nine European countries (Austria, Belgium, Denmark, Finland, France, Germany, Italy, Spain, and Switzerland) plus Canada.

Results

A total of 921 patients on alirocumab were involved [modified intention-to-treat (mITT) analysis], including 114 (12.4%) subjects from CEE countries. Therapy in CEE vs. other countries was numerically more frequently started with lower alirocumab dose (75 mg) at the first visit (74.6 vs. 68%, p = 0.16). Since week 36, the higher dose was predominantly used in CEE patients (150 mg dose in 51.6% patients), which was maintained by the end of the study. Altogether, alirocumab dose was significantly more often increased by CEE physicians (54.1 vs. 39.9%, p = 0.013). Therefore, more patients achieved LDL-C goal at the end of the study (<55 mg/dl/1.4 mmol/L and 50% reduction of LDL-C: 32.5% vs. 28.8%). The only factor significantly influencing the decision on dose of alirocumab was LDL-C level for both countries' groups (CEE: 199.2 vs. 175.3 mg/dl; p = 0.019; other: 205.9 vs. 171.6 mg/dl; p < 0.001, for 150 and 75 mg of alirocumab, respectively) which was also confirmed in multivariable analysis (OR = 1.10; 95% CI: 1.07-1.13).

Conclusions

Despite larger unmet needs and regional disparities in LDL-C targets achievement in CEE countries, more physicians in this region tend to use the higher dose of alirocumab, they are more prone to increase the dose, which is associated with a higher proportion of patients reaching LDL-C goals. The only factor that significantly influences decision whether to increase or decrease the dose of alirocumab is LDL-C level.

Role of the advanced nurse practitioner within the vascular team: A qualitative study of vascular physicians and nurses

Objective

To assess the perception of Advanced Nurse Practitioners (ANP) by physicians and nurses in vascular medicine. As the status of ANP in France was recently enacted by law in 2018, we aimed to investigate physicians and nurses working with patients suffering from Peripheral Artery Disease (PAD) to gather their opinions and draw the cooperation outlines these practitioners could have with an ANP.

Methods

A qualitative study based on in-depth interviews was conducted among healthcare practitioners taking care of patients with PAD: 10 physicians working either in a private practice settings or hospital settings or both, and eight nurses working within a hospital inpatients vascular unit. Verbatim responses were extracted and coded according to a continuous thematization method.

Results

Three main features emerged from participants' responses. Vascular medicine has a specific organization with a significant lack of time and staff to fulfill the mission regarding patients' severity of illness. Second, the ANP is wanted to fill part of this gap. The expected benefits include a smoother care pathway and increased capacity for cardiovascular education and prevention, especially during consultations. Lastly, some clarification is required to integrate such new practitioners within vascular teams already in place.

Conclusion

Advanced nurse practitioners could be the missing link in a "Vascular team" by creating a continuum in the care of patients with PAD, ensuring clinical assessment, nursing supervision, adverse event screening, and renewing drug prescriptions with the required adaptations while ensuring essential part of therapeutic education adapted to each patient.

The approach of Iranian clinical pharmacists in the treatment of dyslipidemia based on international guidelines

Introduction: Optimal treatment of dyslipidemia is a top priority in the prevention of cardiovascular diseases. For this purpose, clinicians in Iran usually refer to four current international guidelines. The aim of this study was to assess the approach of Iranian clinical pharmacists in the treatment of dyslipidemia based on international guidelines. Methods: A structured questionnaire was prepared. Questions (n=24) included the demographics (n=7), dyslipidemia references (n=3), dyslipidemia general knowledge of respondents (n=10), and questions (n=4) designed based on the difference among the latest version of guidelines participants stated they use in their practice. After validity conformation, the questionnaire was distributed to 120 clinical pharmacists, electronically from May to August 2021. Results: Response rate was 77.5% (n=93). The majority of participants (80.6%, n=75) claimed to have used the 2018 ACC/AHA guideline. The Median (interquartile range [IQR]) score of the general knowledge questions was 5.0 (2.0) out of 10. The Median (IQR) score of questions designed based on the difference among guidelines was calculated 3(1) out of 4. There was no significant (P=0.25) difference in score among participants according to their guideline selection. Moreover, the gender and length of experience as a clinical pharmacist had no significant (P>0.05) effect on the score of participants. Conclusion: In this study, Iranian clinical pharmacists answered half of the dyslipidemia general knowledge questions correctly. Also, Participants were up-to-date on 75% of the questions designed based on the latest version of the guideline they had been using in their practice.

Cardiovascular Risk in Patients with Dyslipidemia and Their Degree of Control as Perceived by Primary Care Physicians in a Survey-TERESA-Opinion Study

OBJECTIVE

The aim of this study was to evaluate, through a survey, the opinion of primary care (PC) physicians on the magnitude of dyslipidemia and its degree of control in their clinical practice.

MATERIALS AND METHODS

An ecological study was carried out, in which the physicians were invited to participate by means of an online letter. Data were collected at a single timepoint and were based only on the experience, knowledge, and routine clinical practice of the participating physician.

RESULTS

A total of 300 physicians answered the questionnaire and estimated the prevalence of dyslipidemia between 2% and 80%. They estimated that 23.5% of their patients were high-risk, 18.2% were very high-risk, and 14.4% had recurrent events in the last 2 years. The PC physicians considered that 61.5% of their patients achieved the targets set. The participants fixed the presence of side-effects to statins at 14%. The statin that was considered safest with regard to side-effects was rosuvastatin (69%).

CONCLUSIONS

PC physicians in Spain perceive that the CVR of their patients is high. This, together with the overestimation of the degree of control of LDL-C, could justify the inertia in the treatment of lipids. Moreover, they perceive that one-sixth of the patients treated with statins have side-effects.

Physicians and pharmacists' clinical knowledge of statin therapy and monitoring parameters, and the barriers to guideline implementation in clinical practice

BACKGROUND

Millions of individuals worldwide use statins, and their significant impact on cardiovascular disease (CVD) has been well-established. However, a lack of knowledge about the up-to-date guideline recommendations regarding statin therapy is a common barrier to implementation in clinical practice. Therefore, the present study aimed to assess the current clinical knowledge about statin therapy and its monitoring parameters. Also, we evaluated the barriers to cholesterol management guideline implementation in Yemen.

METHODS

This observational cross-sectional study was conducted over four months, from June/2021 to September/2021, in Sana'a, Yemen. A validated questionnaire was distributed face-to-face to 650 participants (350 physicians and 300 pharmacists). Physicians and pharmacists from governmental and private hospitals and those working in private clinics or community pharmacies were included in the study.

RESULTS

A total of 496 participants filled out the survey, with 22 being excluded due to incomplete data. So, the study has an overall response rate of 72.9% (474). The majority of pharmacists (81.8%) and physicians (78.7%) could not identify the patient group that needed ASCVD risk assessment before statin therapy initiation. Although a significant proportion of respondents knew of the fact that high-intensity statins are recommended for patients with ASCVD (65.4%) and primary hypercholesterolemia (58.4%), the majority of physicians and pharmacists could not identify the high (61.6% and 66.7.3%, respectively) and moderate statin-intensity doses (72.2% and 68.6%, respectively). Only 21.9% of all respondents knew that atorvastatin and rosuvastatin can be administered at any time of the day. Similarly, a low overall rate of respondents (19.6%) knew that atorvastatin does not need dose adjustment in chronic kidney diseases, with a statistically significant difference in knowledge between physicians and pharmacists (12.5% vs. 25.6%, p <0.001, respectively). Notably, only 39.2% of participants were aware that statins are not safe to use during breastfeeding. Around half of respondents (52.3%) correctly identify the duration (4 to 12 weeks) at which LD-C measuring is recommended after therapy initiation or dose change. The lowest knowledge scores for respondents were related to statin-drug interactions. Age, experience, degree, and previous guideline exposure were all significantly associated with the knowledge scores (p <0.05). The four most perceived barriers to implementing cholesterol management guidelines were no audit on adherence to the guidelines in the workplace (73.4%), insufficient resources to adequately implement and follow up on the guideline's recommendations (73.6%), patient's financial status (75.7%), and lack of familiarity about the guideline's latest recommendations (63.3%).

CONCLUSION

Physicians and pharmacists had suboptimal clinical knowledge regarding statin therapy, dose intensities, drug-drug interaction, contraindications, and monitoring parameters. Therefore, physicians' and pharmacists' educational interventions regarding the up-to-date recommendation about statins are recommended.

Non-acute chest pain in primary care; referral rates, communication and guideline adherence: a cohort study using routinely collected health data

BACKGROUND

The prevalence of coronary artery disease is increasing due to the aging population and increasing prevalence of cardiovascular risk factors. Non-acute chest pain often is the first symptom of stable coronary artery disease. To optimise care for patients with non-acute chest pain and make efficient use of available resources, we need to know more about the current incidence, referral rate and management of these patients.

METHODS

We used routinely collected health data from the STIZON data warehouse in the Netherlands between 2010 and 2016. Patients > 18 years, with no history of cardiovascular disease, seen by the general practitioner (GP) for non-acute chest pain with a suspected cardiac origin were included. Outcomes were (i) incidence of new non-acute chest pain in primary care, (ii) referral rates to the cardiologist, (iii) correspondence from the cardiologist to the GP, (iv) registration by GPs of received correspondence and; (v) pharmacological guideline adherence after newly diagnosed stable angina pectoris.

RESULTS

In total 9029 patients were included during the study period, resulting in an incidence of new non-acute chest pain of 1.01/1000 patient-years. 2166 (24%) patients were referred to the cardiologist. In 857/2114 (41%) referred patients, correspondence from the cardiologist was not available in the GP's electronic medical record. In 753/1257 (60%) patients with available correspondence, the GP did not code the conclusion in the electronic medical record. Despite guideline recommendations, 37/255 (15%) patients with angina pectoris were not prescribed antiplatelet therapy nor anticoagulation, 69/255 (27%) no statin and 67/255 (26%) no beta-blocker.

CONCLUSION

After referral, both communication from cardiologists and registration of the final diagnosis by GPs were suboptimal. Both cardiologists and GPs should make adequate communication and registration a priority, as it improves health outcomes. Secondary pharmacological prevention in patients with angina pectoris was below guideline standards. So, proactive attention needs to be given to optimise secondary prevention in this high-risk group in primary care.

Primary care physicians' awareness and perceptions on adherence to primary cardiovascular disease prevention guidelines in Lebanon: A cross-sectional study

OBJECTIVES

To assess the awareness and have an insight on practice patterns of primary care physicians (PCPs) with respect to several professional primary cardiovascular diseases (CVDs) preventive guidelines.

METHODS

This is a cross-sectional study, questionnaire-based using a non-probability convenience sampling. Data collection occurred at the annual conferences of the Lebanese Societies of General Practice, Family Medicine, and Internal Medicine in Lebanon. 104 PCPs were recruited.

MAIN OUTCOME MEASURES

Awareness and practices of CVDs preventive guidelines.

RESULTS

The response rate was 37%. Awareness of the various CVD preventive guidelines was high among PCPs (&gt;81%). Around 69% of PCPs reported that they always calculate the total cardiovascular risk assessment score. Gaps in managing patients according to guidelines' recommendations were higher in statin initiation compared to antihypertensive initiation. There is over prescription of statin in low risk patients and underutilization in high risk patients. Around 20% of PCPs would initiate aspirin for a low risk patient. Around 17% of physicians do not perform abdominal aortic aneurysm screening.

DISCUSSION

Although PCPs demonstrated high level of awareness regarding CVD preventive guidelines, gaps remain present in managing patients according to guidelines' recommendations. Less adherence to guidelines will increase mortality and affect patient care.

A mixed methods study of the awareness and management of familial hypercholesterolaemia in Irish general practice

Introduction

Familial Hypercholesterolemia (FH) is one of the most common genetic disorders, with an estimated global prevalence of 1:200-500, which leads to premature cardiovascular disease. Nevertheless, public and professional awareness of FH is often lacking, with an estimated 20,000 largely undiagnosed cases in Ireland.

Purpose

The overall aim of the project was to test the feasibility of a model of care that would include electronic record screening, clinical assessment, and coding of possible FH patients across a network of general practices in Ireland. In addition, a secondary aim was to gauge the awareness and knowledge of FH across the network.

Methods

This study took part in multiple phases, employing a mixed methods design. The study included a validated questionnaire, tailored online educational resources, a retrospective chart review of patients with a history of elevated LDL cholesterol (LDLc) and an active review with a selection of those patients. Results were analyzed using SPSS V27, where descriptive statistics and relevant correlation tests were employed.

Results

Eighteen general practices agreed to take part in the study. In the initial survey, respondents rated their personal and practice familiarity with FH as slightly below average. Around one-third of respondents were not aware of FH guidelines. Of over 55,000 adult patient records searched, only 0.2% had a recorded FH diagnosis and 3.9% had ever had an LDLc above 4.9 mmol/l. Eight practices completed 198 chart reviews. Among these, 29.8% of patients had a family history recorded, and 22.2% had a family history of CVD recorded. Female patients had higher averages for highest and recent LDLc. Seventy patients underwent a clinical review-with 27% of these patients identified as "probable" or "definite FH." There was a statistically significant (p = 0.002) relationship between FH status and whether the patient had other CVD risk factors.

Conclusion

General practitioners in Ireland had similar levels of awareness of FH compared to findings from elsewhere. The activities discussed encouraged clinicians to consider FH when talking to their patients, especially those with elevated LDLc at an early age. Broader awareness of the condition could increase conversations about FH and benefit patient outcomes.

Achievement of target blood pressure among community residents with hypertension and factors associated with therapeutic failure in the northern territory of Japan

OBJECTIVE

This study aimed to determine the rate of achieving the target blood pressure (BP) defined by Japanese hypertension management guidelines and to examine factors associated with achieving the target BP.

METHODS

This cross-sectional study, which was conducted between January 2012 and December 2015, examined the BP control status and associated factors among 9,016 Japanese community residents with hypertension. Residents were divided into the following six groups: G1, young, middle-aged, and early-phase elderly patients; G2, patients with cerebrovascular disease; G3, patients with coronary artery disease; G4, patients with chronic kidney disease with proteinuria; G5, patients with diabetes; and G6, patients with chronic kidney disease without proteinuria. BP target achievement rates were calculated for each group. A multivariate analysis identified factors associated with "therapeutic failure" of target BP.

RESULTS

The target BP was achieved by 52.6% participants in G1, 84.3% in G2, 50.6% in G3, 45.6% in G4, 48.7% in G5, and 75.0% in G6. The body mass index and receiving antilipidemic medication were associated with therapeutic failure.

CONCLUSION

This study shows that achievement rates for treatment goals among Japanese patients with hypertension are still low. Body mass index and treatment of dyslipidemia may be associated with the control of BP.

Physicians’ Attitudes Against Clinical Practice Guidelines on the Use of Guidelines: A Scale Development Study

This study aims at developing scale measuring attitudes of physicians against clinical practice guidelines (CPGs) and investigate whether the attitude of physicians against CPGs has an effect on the use of CPGs. ‘The Physicians’ Attitudes Against CPGs and The Use of CPGs’ was developed and used to collect data from the physicians working in a public education and research hospital. Physicians’ attitudes that were constructed as an upper latent variable were significant, positive and highly effective on the use of CPGs. Furthermore, the attitude upper latent variable explained 30% of the variance in the observed variable for the use of CPGs. The attitude upper latent variable was affected significantly, positively and at a remarkably high level by positive attitude latent variable while it was affected significantly, negatively and at a remarkably high level by negative attitude latent variable. Physicians’ attitudes against CPGs were found to be a highly important factor in the use of CPGs. And it was also observed that physicians’ positive attitudes against CPGs affected the use of CPGs in a positive way while negative attitudes had negative effect on use of CPGs.

Lipid-lowering therapy use in primary and secondary care in Central and Eastern Europe: DA VINCI observational study

BACKGROUND AND AIMS

Central and Eastern Europe (CEE) is a largely understudied region, despite having the highest cardiovascular disease mortality in Europe. This analysis aimed to assess the proportion of patients in CEE who achieved their LDL-C goals based on individual cardiovascular risk recommended by the 2016 and 2019 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) guidelines.

METHODS

The DA VINCI study was a cross-sectional observational study of primary and secondary prevention patients receiving lipid-lowering therapy across Europe between June 2017 and November 2018.

RESULTS

In total, 2154 patients were enrolled from the Czech Republic (n = 509), Hungary (n = 319), Poland (n = 460), Romania (n = 259), Slovakia (n = 123) and Ukraine (n = 484). At LDL-C measurement, most patients were on either moderate- or high-intensity statin monotherapy (53% and 32%, respectively). Despite this, only 44% of patients achieved risk-based LDL-C goals recommended by the 2016 ESC/EAS guidelines, ranging from 21% in Ukraine to 50% in Hungary and Romania. Only 24% of patients overall achieved the risk-based LDL-C goals recommended by the 2019 ESC/EAS guidelines, ranging from 11% in Ukraine to 32% in Poland.

CONCLUSIONS

Among patients receiving lipid-lowering therapy, more than half did not achieve their 2016 LDL-C goals. In one of the first comparative analyses evaluating 2019 risk-based goal attainment among countries in CEE, three-quarters of patients did not meet their 2019 LDL-C goals, highlighting a significant gap between guidelines and clinical practice for lipid management in CEE.

Management of LDL-cholesterol levels in patients with Diabetes Mellitus in Cardiology Practice: Real-life evidence of Under-treatment from the EPHESUS registry

BACKGROUND AND AIMS

Effective treatment of high low-density lipoprotein cholesterol (LDL-C) levels has been shown to improve cardiovascular outcomes of patients with diabetes mellitus (DM). Herein, we aimed to provide insight to the real-life management of patients with DM in terms of LDL-C goal attainment and adherence to lipid management recommendations. Our objective was also to reveal the reasons of poor LDL-C goal attainment by assessing the perceptions of both physicians and patients.

METHODS

We compared the diabetic and non-diabetic patients from the database of a nationwide registry conducted in cardiology outpatient clinics with regard to the demographic characteristics, educational status, comorbidities, medications, laboratory parameters and LDL-C goal attainment. Also, both the patients and attending physicians were surveyed to analyse perceptions and awareness of hypercholesterolemia.

RESULTS

Of the 1868 consecutively enrolled patients, 873 (47%) had DM. Proportion of patients on statins was significantly lower in patients with DM (67.8% vs 55.3%; P < .001). The proportion of patients who attained LDL-C targets were lower among the diabetic patients (17.8% vs 15%; P = .06). The most common causes of the discontinuation of statin therapy were negative media coverage about statins (32.1%), and recommendations of physicians to stop the lipid lowering therapy (29.6%). Analysis of the physician survey revealed that the physicians could determine the off-target patients accurately (negative predictive value 98.4%) while the positive predictive value (48.8%) was low. The reasons for not attaining the LDL-C goals in diabetic patients were not prescription of statins (38%) and inadequate (eg low-dose, non-adherent) statin (28.3%) dosages.

CONCLUSIONS

In real-life clinical cardiology practice, diabetic patients are far below the recommended LDL-C treatment goals. High-intensity statin treatment in diabetic population is still avoided because of the concerns about polypharmacy and drug interactions. Also, the inertia of physicians and even cardiologists is probably a major cause of refraining of prescription of optimal statin dosages.

Experience of Patients with Diabetes and Other Cardiovascular Risk Factors with Health Professionals and Healthcare in Spain

We aimed to evaluate the experience of patients with type 2 diabetes (T2DM) with healthcare received in Spain. This was a retrospective, observational study in patients with T2DM cared for in primary healthcare (PHC) centers. A cross-sectional analysis of the patients' experience data was performed using the Instrument for the Evaluation of the Experience of Chronic Patients (IEXPAC). A total of 475 patients with T2DM were recruited from 36 PHC centers, of which 248 (52.2%) completed the IEXPAC questionnaire. The IEXPAC total mean score (range 0-10) was 7 points, with an average "new relational model" score of 2.5 points. The mean continuity of care score after hospital discharge was 6.2 points. The results showed that 8% of the patients always or almost always used the internet to check their medical history, appointments or other data from their healthcare service, and 15% responded that healthcare professionals always or almost always informed them of forums or other reliable internet sites to obtain information about their illness. The study results show that there is a wide margin for improvement in the experience of patients with T2DM with healthcare in Spain, especially regarding the information patients receive or can obtain.

Management of Dyslipidaemia in Real-world Clinical Practice: Rationale and Design of the VIPFARMA ISCP Project

Dyslipidaemia plays a major role in the pathogenesis of atherosclerosis. Every year, scientific institutions publish cardiovascular prevention guidelines with updated goals and recommendations based on new evidence. However, medical barriers exist that make achieving these goals difficult and gaps between guidelines and best daily clinical practice still persist. The International Society of Cardiovascular Pharmacotherapy designed the Surveillance of Prescription Drugs in the Real World Project (VIPFARMA ISCP), a survey for physicians who manage lipid disorders in high-risk patients. Seven clusters of questions will be analysed comprising demographics, institution profile, access to continuing medical education, clinical practice profile, attitude regarding use of statins, knowledge regarding proprotein convertase subtilisin/kexin type 9 inhibitors and attitudes regarding medical decisions about triglycerides. The present study will be the first part of a larger programme and aims to shed light on barriers between lipid-lowering drug therapy recommendations in the 2019 European Society of Cardiology guidelines and clinical practice in different countries.

Current perceptions and practices in lipid management: results of a European Society of Cardiology/European Atherosclerosis Society Survey

AIMS

We sought to evaluate physicians' opinions and practices in lipid management.

METHODS AND RESULTS

A web-based survey by the European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS) was distributed to 70 696 individuals at two time points, before and after publication of the 2019 ESC/EAS dyslipidaemia guidelines. Respondents (1271 in the first and 1056 in the second part) were most commonly cardiologists in Europe. More than 90% of participants reported that they regularly measure lipid levels and discuss lipid-lowering treatment with patients. More than 87% found the use of LDL-C goals useful or potentially useful, although it was acknowledged that recommended goals are frequently not achieved. Regarding the LDL-C goal according to the 2019 guidelines (<1.4 mmol/L for very high-risk patients), more than 70% of respondents felt that it is based on solid scientific evidence, but 31% noted that implementation should also consider available local resources and patient preferences. Statin intolerance was perceived as infrequent, affecting 1-5% of patients according to most respondents but was the main reason for not prescribing a statin to secondary-prevention patients, followed by patient non-adherence. Although most respondents reported that 11-20% of secondary-prevention patients have an indication to add a non-statin medication, fewer patients (<10% according to most respondents) receive these medications.

CONCLUSIONS

This survey shows a high level of acceptance of the LDL-C treatment goals recommended by current ESC/EAS guidelines. Although patient-related factors were the main reported reasons for suboptimal lipid-lowering therapy, physician inertia to intensify treatment cannot be excluded as an additional contributing factor.

Compliance to hypertensive prescribing guidelines and blood pressure control in elderly patients in Namibia: findings and implications

Objective

Resources-limited countries in sub-Saharan Africa are facing a crisis of hypertensive-related morbidity, mainly due to poor blood pressure (BP) control. The study aimed to evaluate BP control and hypertensive prescribing for elderly patients in a resource-limited setting.

Methods

Hospital-based survey assessing hypertensive prescribing practices among elderly patients (age, ≥60years) at a leading ambulatory care clinic in Namibia. The primary and secondary outcomes were compliance with prescribing guidelines, prescribing patterns and BP control respectively. Data were collected using patient exit interviews and a review of their prescription records. Data were analyzed using descriptive statistics using SPSS v25.

Key findings

Of the 189 elderly patients recruited, 69.3% were females, mean age was 70.3 ± 8.5 years and 2.6% had HIV. 61.4% of the prescriptions complied with the prescribing guidelines in terms of treatment choice and 78.3% (n = 148) had a poor BP control. 61.4% had at least one comorbidity, mainly diabetes mellitus (32.2%) or cardiac disease (20%). On average, 4.5 medicines were prescribed per patient and 4.8% were out of stock. Prevalence of non-INN prescribing was 64%. Diuretics, renin-angiotensin inhibitors were the most prescribed antihypertensive, 73.9% (n = 138/189) and 51.9% (n = 98/189) respectively. 90% of patients with good BP control were on ≥3 medicines compared to 77% for patients with poor BP controlled.

Conclusion

Whilst compliance with prescribing guidelines is modest, the sub-optimal BP control, high prevalence of co-morbidities and over prescribing with non-INN products is discouraging. Pharmacist-led medication audits could improve hypertensive prescribing and BP control among elderly patients, and we will be following this up

Use of guideline-recommended drug therapy in patients undergoing percutaneous coronary intervention for stable coronary heart disease in Germany: a multilevel analysis of nationwide routine data

OBJECTIVES

To determine the prescription of guideline recommended drug therapy in patients with stable coronary heart disease (sCHD) prior to percutaneous coronary intervention (PCI) in Germany and to examine the role of patient characteristics and features of regional healthcare supply in a multilevel model.

DESIGN

Secondary data analysis of factors associated with the prescription of guideline recommended drug therapy using a multilevel model to analyse regional-level effects, over and above the effects of patient-level demographic and health status.

SETTING

Office-based prescriptions in the year prior to the invasive procedure.

PARTICIPANTS

A linked nationwide dataset from Germany's three largest statutory health insurance funds of all patients receiving PCI in the year 2016.

MAIN OUTCOME MEASURES

Patients' odds of receiving optimal medical therapy and symptom-oriented therapy within 1 year prior to PCI.

RESULTS

68.6% of patients received at least one lipid-lowering drug and one symptom-oriented therapy prior to PCI. 43.6% received at least two agents to control their symptoms. Patients who received treatment in accordance with the recommendations had a greater number of diagnosed risk factors, a more severe history of cardiac disease and used a higher volume of ambulatory office-based physician services. The prescriptions prevalence for the symptom-oriented therapies differed significantly between eastern and western Germany, with a higher prevalence in the eastern districts.

CONCLUSIONS

Guidelines can only provide decision-making corridors, and the applicability of recommendations must always be assessed on a case by case basis. Nevertheless, our analysis indicates that the prevalence of prescriptions in routine practice is subject to substantial variation and that conservative therapy options are not fully exhausted prior to PCI. This suggests that there might be room for improvement in the care of patients with sCHD.

Poor cardiovascular health status among Chinese women

BACKGROUND

Systematic investigation and analysis of cardiovascular health status (CVHS) of Chinese women is rare. This study aimed to assess CVHS and atherosclerotic cardiovascular disease (ASCVD) burden in the Chinese women physicians (CWP) and community-based non-physician cohort (NPC).

METHODS

In this prospective, multicenter, observational study, CVHS using the American Heart Association (AHA) defined 7 metrics (such as smoking and fasting glucose) and ASCVD risk factors including hypertension, hyperlipidemia and type-2 diabetes were evaluated in CWP compared with NPC.

RESULTS

Of 5832 CWP with a mean age of 44 ± 7 years, only 1.2% achieved the ideal CVHS and 90.1% showed at least 1 of the 7 AHA CVHS metrics at a poor level. Total CVHS score was significantly decreased and ASCVD risk burden was increased in postmenopausal subjects in CWP although ideal CVHS was not significantly influenced by menopause. Compared to 2596 NPC, fewer CWP had ≥ 2 risk factors (8% vs. 27%, P < 0.001); CWP scored significantly higher on healthy factors, a composite of total cholesterol, blood pressure, fasting glucose (P < 0.001), but, poorly on healthy behaviors (P < 0.001), specifically in the physical activity component; CWP also showed significantly higher levels of awareness and rates of treatment for hypertension and hyperlipidemia, but, not for type-2 diabetes.

CONCLUSION

Chinese women's cardiovascular health is far from ideal and risk intervention is sub-optimal. Women physicians had lower ASCVD burden, scored higher in healthy factors, but, took part in less physical activity than the non-physician cohort. These results call for population-specific early and improved risk intervention.

Assessment of family and internal medicine physicians knowledge and practice of bronchial asthma at Riyadh city

Background:

The prevalence of bronchial asthma (BA) is increasing in the Kingdom of Saudi Arabia. The knowledge and adherence to guidelines by physicians can play a major role in controlling asthma.

Aim:

To assess the knowledge and practice of family medicine and internal medicine physicians about BAat King Saudi University medical city in Riyadh, Kingdom of Saudi Arabia.

Methodology:

A cross-sectional survey study was conducted. All family and internal medicine physicians at King Khalid University Hospital were included. A total of 180 physicians participated. The questionnaire was developed according to the Global Initiative for Asthma (GINA) guideline to assess the knowledge and practice of physicians towards bronchial asthma, included questions (diagnosis, severity classification, management, and referral).

Results:

All participated physicians knowledge and practice level about BAwaslow; the average scores were around 50%. The comparison between family and internal medicine physicians' knowledge shows insignificant differences. The only exception is the management part; family medicine physicians show better results than internal medicine physicians. The years of experience and higher qualification show significant improvement in the level of the knowledge scores.

Conclusion:

The knowledge of physicians about the diagnosis, assessment of severity, management, and referral of BA was unsatisfactory. We recommend an adoption of a special asthma clinic for teaching, supervising, and managing purposes assigned to an expert consultant.

Gaps in beliefs and practice in dyslipidaemia management in Japan, Germany, Colombia and the Philippines: insights from a web-based physician survey

BACKGROUND

Implementing evidence-based management of dyslipidaemia is a challenge worldwide.

OBJECTIVES

To understand physician beliefs and behaviour and identify uncertainties in dyslipidaemia management across four world regions.

METHODS

Web-based survey of 1758 physicians in Japan, Germany, Colombia and the Philippines who were selected randomly from existing databases. Key inclusion criteria were 1) for cardiologists and diabetes/endocrinology specialists: ≥50 dyslipidaemia patients examined in the last month; 2) for specialists in neurology/neurosurgery/stroke medicine: ≥50 dyslipidaemia patients and ≥ 20 patients with a history of ischaemic stroke examined in the last month; and 3) for specialists in nephrology and general medicine: based at centres with ≥20 beds and ≥ 50 dyslipidaemia patients examined in the last month. The self-report survey covered dyslipidaemia management, target low-density lipoprotein cholesterol (LDL-C) levels in different patient groups, and statin safety. All physicians gave voluntary consent and all data were anonymised. Analysis was solely descriptive.

RESULTS

The survey highlighted key areas of uncertainty in dyslipidaemia management in the four countries. These related to LDL-C targets in different patient groups, the safety of low LDL-C levels, the safety of statins, especially for effects on cognitive, renal and hepatic function and for haemorrhagic stroke risk, and lipid management strategies in patients with chronic kidney disease, including those with concomitant hypertriglyceridaemia.

CONCLUSIONS

This survey of physicians in Japan, Germany, Colombia and the Philippines has identified key gaps in knowledge about dyslipidaemia management. These relate to the safety of low LDL-C levels, the safety of statins, and lipid management of chronic kidney disease. The findings from this survey highlight the need for further education to improve the implementation of guideline recommendations for dyslipidaemia management.

Optimising implementation of European guidelines on cardiovascular disease prevention in clinical practice: what is needed?

Cardiovascular disease is a model example of a preventable condition for which practice guidelines are particularly important. In 2016, the joint task force created by the European Society of Cardiology (ESC) together with 10 other societies released the new version of the European guidelines on cardiovascular disease prevention. To facilitate the implementation of the ESC guidelines, a dedicated prevention implementation committee has been established within the European Association of Preventive Cardiology. The paper will first explore potential barriers to the guidelines’ implementation. It then develops a discussion that seeks to inform the future development of the committee’s work, including a new definition of the guidelines’ stakeholders (health policy-makers, healthcare professionals and health educators, patient organisations, entrepreneurs and the general public), future activities within four specific areas: strengthening awareness of the guidelines among stakeholders; supporting organisational changes to facilitate the guidelines’ implementation; motivating stakeholders to utilise the guidelines; and present ideas on new implementation strategies. Providing multifaceted cooperation between healthcare professionals, healthcare management executives and health policy-makers, the novel approach proposed in this paper should contribute to a wider use of the 2016 ESC guidelines and produce desired effects of less cardiovascular disease morbidity and mortality. Furthermore, the solutions presented within the paper may constitute a benchmark for the implementation of practice guidelines in other medical disciplines.

Achievement of LDL-C Targets Defined by ESC/EAS (2011) Guidelines in Risk-Stratified Korean Patients with Dyslipidemia Receiving Lipid-Modifying Treatments

BACKGROUND

This study assessed the proportion of risk-stratified Korean patients with dyslipidemia achieving their low-density lipoprotein cholesterol (LDL-C) targets as defined by the European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) (2011) guidelines while receiving lipid-modifying treatments (LMTs).

METHODS

In this multicenter, cross-sectional, observational study, we evaluated data from Korean patients aged ≥19 years who were receiving LMTs for ≥3 months and had an LDL-C value within the previous 12 months on the same LMT. Data were collected for demographics, cardiovascular (CV) risk factors, medical history, and healthcare consumption. Patients were risk-stratified according to the ESC Systematic COronary Risk Evaluation (SCORE) chart and LDL-C target achievement rate was assessed.

RESULTS

Guideline-based risk-stratification of the 1,034 patients showed the majority (72.2%) to be in the very high-risk category. Investigators' assessment of risk was underestimated in 71.6% compared to ESC/EAS guidelines. Overall LDL-C target achievement rate was 44.3%; target achievement was the highest (66.0%) in moderate-risk patients and the lowest (39.0%) in very high-risk patients. Overall 97.1% patients were receiving statin therapy, mostly as a single-agent (89.2%). High-intensity statins and the highest permissible dose of high-intensity statins had been prescribed to only 9.1% and 7.3% patients in the very high-risk group, respectively. Physician satisfaction with patients' LDL-C levels was the primary reason for non-intensification of statin therapy.

CONCLUSION

Achievement of target LDL-C level is suboptimal in Korean patients with dyslipidemia, especially in those at very high-risk of CV events. Current practices in LMTs need to be improved based on precise CV risk evaluation posed by dyslipidemia.

Assessment of medical intern's knowledge, awareness and practice of familial hypercholesterolemia at academic institutes in Jeddah, Saudi Arabia

Background

Familial Hypercholesterolemia (FH) is a serious under-diagnosed disease characterized by raised low-density lipoprotein cholesterol (LDL-C) and premature coronary artery diseases (CAD). The scarcity of FH reported patients in Saudi Arabia indicates lack of FH awareness among physicians.

Objective

The goal of this research was to assess knowledge, awareness, and practice (KAP) about FH disorder among Saudi medical interns and to identify areas that need educational attention.

Methods

This cross-sectional study involved 170 Saudi medical interns (83 males and 87 females) from academic institutes in Jeddah, Saudi Arabia. The interns were asked to fill an online FH-KAP questionnaire. Total score for each separate domain measured by adding correct answers.

Results

Although, knowledge of FH definition (76.5%) and classical lipid profile (52.4%) were reasonable; knowledge on inheritance (43.5%), prevalence (12.4%) and CAD risks (7.1%) were poor. Knowledge score was significantly higher in female than male (7.5 ± 3 vs. 5.3 ± 2.6, P < 0.001). Regarding awareness, 54.1% were familiar with FH disorder, 50.6% with the presence of lipid clinic but only 16.5% were acquainted with guidelines. Furthermore, in the practice domain 82.9% selected statin as first line treatment and 62.9% chose routinely checking the rest of the family, while 15.3% chose ages 13–18 years to screen for hypercholesterolemia in patients with a positive family history of premature CAD.

Conclusion

Substantial defects in FH-KAP among Saudi medical interns were found, emphasizing the importance of professional training. Extensive and constant medical education programs as early as an internship are required to close the gap in CAD prevention.

Improving adherence to cardiovascular guidelines: realistic transition from paper to patient

Introduction: The emphasis on clinical trials to inform evidence-based medicine remains paramount within the cardiovascular community. Although such high-quality evidence is often translated into national and international guidelines, there exists a large gap between guideline development and guideline implementation into daily clinical practice.Areas covered: This article outlines barriers that impede guideline adherence and possible strategies to overcome such barriers. Barriers intrinsic and extrinsic to clinicians are discussed. The structured process of guideline implementation including guideline adoption, diffusion, and dissemination is discussed. Lastly, the authors review in detail the current and potential future elements of guideline diffusion and dissemination.Expert opinion: Improving guideline adherence remains challenging as it requires understanding of and navigation through various barriers. However, further research specific to cardiovascular medicine guidelines is necessary to better understand the objective effectiveness of various strategies employed by guideline writers and medical societies to improve adherence. The cost-effectiveness of nationwide dissemination strategies in improving guideline adherence and patient outcomes is also necessary but is largely unknown.

Perception and self-management of hypertension in Chinese cardiologists (CCHS): a multicenter, large-scale cross-sectional study

OBJECTIVES

To determine the frequency of risk factors for hypertension among Chinese cardiologists using a nation-wide survey.

DESIGN

Multicenter, cross-sectional observational study.

SETTING

2441 hospitals across China were surveyed between September 2016 and August 2017.

PARTICIPANTS

All in-service cardiologists were surveyed (n=28 924).

INTERVENTIONS

WeChat-based electronic data capture system, a social application in China (Tencent, Nanshan, China), was used for data acquisition. Physician subscribed to the WeChat official account of the China Cardiologist Heart Study, and filled out an online questionnaire that included age, gender, level of in-service hospital, professional title, academic degree, area of expertise and cardiovascular risk factors. All information was required.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the presence of cardiovascular risk factors. The secondary outcome was the impact of the risk factors on the occurrence of hypertension.

RESULTS

Among 28 924 Chinese cardiologists who completed the questionnaire, 57.6% had blood pressure of 130-139/80-89 mm Hg (5.3% were taking antihypertensive drugs) and 22.0% had blood pressure >140/>90 mm Hg (36.5% were taking antihypertensive drugs). The multivariable analysis showed that age, gender, academic degree, hospital level, body mass index (BMI), smoking and comorbidities were independently associated with hypertension among cardiologists (all p<0.05). Age, female gender, BMI, smoking, family history of cardiovascular diseases (CVDs) and comorbidities were independently associated with taking antihypertensive drugs among hypertensive cardiologists (all p<0.05). Age, hospital level, professional title, BMI, family history of CVDs and comorbidities were independently associated with reaching target blood pressure among hypertensive cardiologists taking antihypertensive drugs.

CONCLUSION

Chinese cardiologists do not recognise and pay attention to their own blood pressure. Their rate of antihypertensive treatment was low. The identified risk factors could be used to identify cardiologists at higher risk for hypertension and for implementing preventive interventions.

Implementation of home blood pressure monitoring among French GPs: A long and winding road

BACKGROUND

To explore the perception of home blood pressure monitoring (HBPM) by general practitioners (GPs) in everyday practice in order to identify facilitators and barriers to its implementation in daily practice.

METHODS

A qualitative study comprising the conduct of six focus groups between October 2016 and February 2017, gathering 41 general practitioners in primary care practice in Lorraine (North Eastern France), with thematic and comprehensive analysis.

RESULTS

The first reasons given by GPs to explain their difficulties with HBPM (Home Blood Pressure Monitoring) implementation were the usual lack of time, material and human resources. However, all of these motives masked other substantial limiting factors including insufficient knowledge regarding HBPM, poor adherence to recommendations on HBPM and fear of losing their medical authority. GPs admitted that HBPM use could enhance patient observance and decrease therapeutic inertia. Despite this observation, most GPs used HBPM only at the time of diagnosis and rarely for follow-up. One explanation for GP reluctance towards HBPM may be, along with guidelines regarding hypertension, HBPM is perceived as being a binding framework and being difficult to implement. This barrier was more predominantly observed among aging GPs than in young GPs and was less frequent when GPs practiced in multidisciplinary health centers because the logistical barrier was no longer present.

DISCUSSION

In order to improve HBPM implementation in everyday practice in France, it is necessary to focus on GP training and patient education. We must also end "medical power" in hypertension management and turn to multidisciplinary care including nurses, pharmacists and patients.

Percentage low-density lipoprotein-cholesterol response to a given statin dose is not fixed across the pre-treatment range: Real world evidence from clinical practice: Data from the ESC-EORP EUROASPIRE V Study

Aims

Recent European guidelines recommend in patients with atherosclerotic cardiovascular disease to achieve a reduction of low-density lipoprotein-cholesterol of at least 50% if the baseline low-density lipoprotein-cholesterol level is between 1.8 and 3.5 mmol/L. Systematic reviews have associated a given statin/dose combination with a fixed percentage low-density lipoprotein-cholesterol response. Algorithms for detecting cases and estimating the prevalence of familial hypercholesterolaemia often rely on such fixed percentage reductions.

Methods and results

We used data from 915 coronary patients participating in the EUROASPIRE V study in whom atorvastatin or rosuvastatin therapy was initiated at hospital discharge and who were still using these drugs at the same dose at a follow-up visit 6 or more months later. Pre and on-treatment low-density lipoprotein-cholesterol levels were compared across the full low-density lipoprotein-cholesterol range. The prevalence of FH was estimated using the Dutch Lipid Clinic Network criteria, once using observed pre-treatment low-density lipoprotein-cholesterol and once using imputed pre-treatment low-density lipoprotein-cholesterol by following the common strategy of applying fixed correction factors to on-treatment low-density lipoprotein-cholesterol. Inter-individual variation in the low-density lipoprotein-cholesterol response to a fixed statin and dose was considerable, with a strong inverse relation of percentage reductions to pre-treatment low-density lipoprotein-cholesterol. The percentage low-density lipoprotein-cholesterol response was markedly lower at the left end of the pre-treatment low-density lipoprotein-cholesterol range especially for levels less than 3 mmol/L. The estimated prevalence of familial hypercholesterolaemia was 2% if using observed pre-treatment low-density lipoprotein-cholesterol and 10% when using imputed low-density lipoprotein-cholesterol.

Conclusion

The inter-individual variation in the percentage low-density lipoprotein-cholesterol response to a given dose of a statin is largely dependent on the pre-treatment level: the lower the pre-treatment low-density lipoprotein-cholesterol level the smaller the percentage low-density lipoprotein-cholesterol reduction. The use of uniform correction factors to estimate pre-treatment low-density lipoprotein-cholesterol is not justified.

Adherence of cardiologist physicians to the American Heart Association guideline in approach to risk factors of cardiovascular diseases: An experience from a teaching hospital

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death globally and has enormous costs for healthcare systems. This disease has a strong association with lifestyle behaviors. Therefore, applying reliable and effective strategies for prevention and treatment of CVD is important. In this study, we aimed to evaluate the adherence of cardiologist physicians to the American Heart Association (AHA) guideline for prevention of CVD.

METHODS

Using a cross-sectional study, data were gathered for 208 patients using their medical records in the cardiology ward of a general teaching hospital. A physician systematically reviewed the medical records and completed the checklist in each domain. Adherence to the AHA guideline was evaluated in treating physician's choices and recommendations regarding these eight variables: hypertension (HTN), dietary intake, weight management, diabetes management, physical activity, blood lipid management, smoking, and aspirin prescription.

RESULTS

Medical records of 208 patients (109 men and 99 women) with the mean age of 62 ± 14 years were reviewed. The frequency of CVDs was 5.3% for coronary heart failure (HF) and 67.8% for the acute coronary syndrome (ACS). Cardiovascular risk factors of patients were HTN (53.8%), diabetes (34.6%), hyperlipidemia (17.3%), smoking (17.8%), and obesity (31.7%). We found a proportion of 59%, 15%, and 26% for high, moderate, and low adherence to AHA guideline, respectively.

CONCLUSION

Our study showed almost 60% high adherence to the AHA guideline by physicians in a teaching hospital. The most and the least adherence to the AHA guideline were for obesity and diabetes recommendations, respectively. More studies are needed to evaluate preventive guideline adherence in Iran. Establishing national preventive and therapeutic guidelines may increase the physicians' adherence to them.

Primary care physicians' knowledge, attitudes and practices related to metabolic syndrome screening and management in Alahsa, Saudi Arabia

BACKGROUND

The metabolic syndrome (Metabolic syndrome) is a cluster of the most dangerous risk factors for type 2 diabetes mellitus and cardiovascular diseases (CVD), two of the main causes of morbidity and mortality worldwide, which include hyperglycemia, abdominal obesity, lipid abnormalities and high blood pressure.

STUDY DESIGN

a cross-sectional descriptive study.

RESULTS

A predominant number (94.1%) knew what constitutes MS. However, merely more than a quarter of the participant (28%) knew correctly the serum LDL cutoff value for the diagnosis of MS according to IDF criteria. The aim of lipid lowering treatment was known by slightly more than three fourth (78%) of the participants. Two third also knew the target of antihypertensive therapy. More than two third (69.5%) were also aware that waist circumference is one of the criteria for diagnosis of Metabolic syndrome.

CONCLUSION

There is a need to increase the awareness of MS among the PHC Physicians. More training programs need to be planned. A better awareness among primary care physician is warranted for an early diagnosis and effective management of MS in Saudi Arabia.

Physicians' Dietary Knowledge, Attitudes, and Counseling Practices: The Experience of a Single Health Care Center at Changing the Landscape for Dietary Education

Morbidity and mortality associated with cardiovascular disease can be significantly modified through lifestyle interventions, yet there is little emphasis on nutrition and lifestyle in medical education. Improving nutrition education for future physicians would likely lead to improved preparedness to counsel patients on lifestyle interventions. An online anonymous survey of medical residents, cardiology fellows, and faculty in Internal Medicine and Cardiology was conducted at New York University Langone Health assessing basic nutritional knowledge, self-reported attitudes and practices. A total of 248 physicians responded (26.7% response rate). Nutrition knowledge was fair, but few (13.5%) felt adequately trained to discuss nutrition with patients. A majority (78.4%) agreed that additional training in nutrition would allow them to provide better clinical care. Based on survey responses, a dedicated continuing medical education (CME) conference was developed to improve knowledge and lifestyle counseling skills of healthcare providers. In postconference evaluations, attendees reported improved knowledge of evidence-based lifestyle interventions. Most noted that they would prescribe a Mediterranean or plant-based diet and would make changes to their practice based on the conference. An annual CME conference on diet and lifestyle can effectively help interested providers overcome barriers to lifestyle change in clinical practice through improved nutrition knowledge.

Efficacy of a nurse-led lipid-lowering secondary prevention intervention in patients hospitalized for ischemic heart disease: A pilot randomized controlled trial

Background and aims:

Lack of achievement of secondary prevention objectives in patients with ischaemic heart disease remains an unmet need in this patient population. We aimed at evaluating the six-month efficacy of an intensive lipid-lowering intervention, coordinated by nurses and implemented after hospital discharge, in patients hospitalized for an ischaemic heart disease event.

Methods:

Randomized controlled trial, in which a nurse-led intervention including periodic follow-up, serial lipid level controls, and subsequent optimization of lipid-lowering therapy, if appropriate, was compared with standard of care alone in terms of serum lipid-level control at six months after discharge.

Results:

The nurse-led intervention was associated with an improved management of low-density lipoprotein (LDL) cholesterol levels compared with standard of care alone: LDL cholesterol levels ⩽100 mg/dL were achieved in 97% participants in the intervention arm as compared with 67% in the usual care arm ( p value <0.001), the LDL cholesterol ⩽70 mg/dL target recommended by the 2016 European Society of Cardiology guidelines was achieved in 62% vs. 37% participants ( p value 0.047) and the LDL cholesterol reduction of ⩾50% recommended by the American College of Cardiology/American Heart Association in 2013 was achieved in 25.6% of participants in the intervention arm as compared with 2.6% in the usual care arm ( p value 0.007). The intervention was also associated with improved blood pressure control among individuals with hypertension.

Conclusions:

Our findings highlight the opportunity that nurse-led, intensive, post-discharge follow-up plans may represent for achieving LDL cholesterol guideline-recommended management objectives in patients with ischaemic heart disease. These findings should be replicated in larger cohorts.

Awareness of Physicians and Clinical Pharmacists About ACC/AHA Guidelines for Dyslipidemia Management: A Cross-Sectional Study

Introduction:

Cardiovascular diseases (CVDs) are one of the leading causes of morbidity and mortality worldwide. Although genetics could contribute to the incidence of CVD, they are mostly acquired conditions. Management of precipitating factors such as hyperlipidemia can prevent CVD. Therefore, clinical guidelines have been used as a tool to improve patient outcomes and minimize practice variation.

Objective:

The objective of this study was to assess health-care providers’ (physicians and clinical pharmacists) awareness about the latest edition of the American College of Cardiology/American Heart Association (ACC/AHA) guidelines of dyslipidemia management.

Materials and Methods:

To meet the study objective, a self-administered questionnaire was designed based on the recommendations of the latest edition of the ACC/AHA guidelines for dyslipidemia management. After validation, the questionnaire was distributed to physicians and clinical pharmacists in Al-Ahsa province of Saudi Arabia.

Results:

Validation of the questionnaire was carried on 10 participants (Cronbach’s alpha = 0.816). Seventy-seven participants completed the questionnaire (acceptance rate = 51.33%). The majority of participants knew about the release of the ACC/AHA 2013 guidelines for dyslipidemia (77% of the physicians and 48% of the clinical pharmacist). Inadequate knowledge of the major changes in the dyslipidemia management was observed in both study groups with no significant difference between them (the median score for physicians and pharmacists was 4 out of 10 with a range of 1–9, Z = −0.15, P = 0.88).

Conclusion:

Inadequate level of knowledge about practice-changing recommendations of the recent ACC/AHA guidelines for dyslipidemia management was observed among the study participants. This level of knowledge could result in clinical malpractice and worsen management outcomes. Thus, efforts should be in place to raise awareness about the evidence-based management of dyslipidemia and monitor compliance to guidelines and their implementation outcomes.

Smoking cessation: Adherence based on patients' illness perception after coronary artery bypass grafting surgery

Background

Coronary artery bypass grafting surgery (CABG) is a common treatment for coronary artery disease. The patient’s commitment to modify risk factors is necessary to achieve the desired after surgery outcomes. The current study aimed at determining illness perception of patients after CABG, its relation to smoking cessation, and detecting other predictors of smoking cessation.

Methods

The samples of the current cross sectional study were selected from a greater study that was done on patients’ adherence determining for 6 months after CABG surgery. Data collection was performed using a telephone questionnaire with 3 sections: personal and social information, smoking cessation, and illness perception. Data analysis was performed via descriptive statistics, independent t test, and multiple logistic regression analysis through SPSS version 16.

Results

The findings showed that 26.6% of the patients had not stopped smoking for 6 months after CABG, and the mean score of illness perception was 83.28 ± 6.11. The relationship between adherence to smoking cessation and illness perception was not significant. Regression logistics via backward selection to detect factors related to smoking cessation adherence after CABG showed only a lack of hypertension history could predict adherence to smoking cessation (OR = 0.199, P = 0.03).

Conclusions

Based on the results, about one-third of the subjects smoked cigarettes after CABG; therefore, it is critical to plan rehabilitation programs regarding smoking cessation after this surgery.

Association of a Combined Measure of Adherence and Treatment Intensity With Cardiovascular Outcomes in Patients With Atherosclerosis or Other Cardiovascular Risk Factors Treated With Statins and/or Ezetimibe

IMPORTANCE

Both adherence and treatment intensity can alter the effectiveness of lipid-lowering therapy in routine clinical practice.

OBJECTIVE

To evaluate the association of adherence and treatment intensity with cardiovascular outcomes in patients with documented cardiovascular disease (CVD), type 2 diabetes without CVD or chronic kidney disease (CKD), and CKD without CVD.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study using the Clinical Practice Research Datalink from January 2010 through February 2016. United Kingdom primary care was the setting. Participants were newly treated patients who received their first statin and/or ezetimibe prescription between January 1, 2010, and December 31, 2013, plus an additional prescription for statins and/or ezetimibe during the following year.

EXPOSURES

Adherence was assessed annually using the proportion of days covered, with adherent defined as a proportion of days covered of 80% or higher. Treatment intensity was classified according to guidelines based on the expected percentage of low-density lipoprotein cholesterol (LDL-C) reduction as low (<30% reduction), moderate (30% to <50% reduction), or high (≥50% reduction). Adherence and treatment intensity were multiplied to create a combined measure, reflecting treatment intensity after accounting for adherence.

MAIN OUTCOMES AND MEASURES

Composite end point of cardiovascular death or hospitalization for myocardial infarction, unstable angina, ischemic stroke, heart failure, or revascularization. Hazard ratios (HRs) were estimated against patients not treated for 1 year or longer.

RESULTS

Among a total of 29 797 newly treated patients, there were 16 701, 12 422, and 674 patients with documented CVD, type 2 diabetes without CVD or CKD, and CKD without CVD, respectively; mean (SD) ages were 68.3 (13.2), 59.3 (12.4), and 67.3 (15.1) years, and male proportions were 60.6%, 55.0%, and 47.0%. In the documented CVD cohort, patients receiving high-intensity therapy were more likely to be adherent over time (84.1% in year 1 and 72.3% in year 6) than patients receiving low-intensity therapy (57.4% in year 1 and 48.4% in year 6). Using a combined measure of adherence and treatment intensity, a graded association was observed with both LDL-C reduction and CVD outcomes: each 10% increase in the combined measure was associated with a 10% lower risk (HR, 0.90; 95% CI, 0.86-0.94). Adherent patients receiving a high-intensity regimen had the lowest risk (HR, 0.60; 95% CI, 0.54-0.68) vs patients untreated for 1 year or longer. Findings in the other 2 cohorts were similar.

CONCLUSIONS AND RELEVANCE

Results of this study demonstrate that the lowest cardiovascular risk was observed among adherent patients receiving high-intensity therapy, and the highest cardiovascular risk was observed among nonadherent patients receiving low-intensity therapy. Strategies that improve adherence and greater use of intensive therapies could substantially improve cardiovascular risk.

The adoption of hypertension reference framework: An investigation among primary care physicians of Hong Kong

Background

The Hong Kong Government released a Reference Framework (RF-HT) for Hypertension Care for Adults in Primary Care Settings since 2010. No studies have evaluated its adoption by primary care physicians (PCPs) since its release.

Aim

We aimed to evaluate the level of PCPs’ adoption of the RF-HT and the potential barriers of its use in family practice.

Design and setting

A cross-sectional study was conducted by a self-administered validated survey among all PCPs in Hong Kong through various means.

Methods

We assessed the level of and factors associated with its adoption by multivariate logistic regression modelling.

Result

A total of 3,857 invitation episodes were sent to 2,297 PCPs in 2014–2015. We received 383 completed questionnaires. The average score of adoption was 3.43 out of 4.00, and 47.5% of PCPs highly adopted RF-HT in their daily consultations. Male practitioners (adjusted odds ratio [aOR] = 0.524, 95% CI = 0.290–0.948, p = 0.033) and PCPs of public sector (aOR = 0.524, 95% CI = 0.292–0.940, p = 0.030) were significantly less likely to adopt the RF-HT. PCPs with higher training completion or being academic fellow are more likely to adopt RF-HT than those who were “nil to basic training completion” (aOR = 0.479, 95% CI = 0.269–0.853, p = 0.012) or “higher trainee” (aOR = 0.302, 95% CI = 0.093–0.979, p = 0.046). Three most-supported suggestions on RF-HT improvement were simplification of RF-HT, provision of pocket version and promoting in patients.

Conclusion

Among PCP respondents, the adoption level of the RF-HT was high. These findings also highlighted some factors associated with its adoption that could inform targeted interventions for enhancing its use in clinical practice.

Feasibility of cardiovascular disease risk assessments in rheumatology outpatient clinics: experiences from the nationwide NOCAR project

Objective

The European League Against Rheumatism recommends implementing cardiovascular disease (CVD) risk assessments for patients with inflammatory joint diseases (IJDs) into clinical practice. Our goal was to design a structured programme for CVD risk assessments to be implemented into routine rheumatology outpatient clinic visits.

Methods

The NOrwegian Collaboration on Atherosclerosis in patients with Rheumatic joint diseases (NOCAR) started in April 2014 as a quality assurance project including 11 Norwegian rheumatology clinics. CVD risk factors were recorded by adding lipids to routine laboratory tests, self-reporting of CVD risk factors and blood pressure measurements along with the clinical joint examination. The patients’ CVD risks, calculated by the European CVD risk equation SCORE, were evaluated by the rheumatologist. Patients with high or very high CVD risk were referred to their primary care physician for initiation of CVD preventive measures.

Results

Data collection (autumn 2015) showed that five of the NOCAR centres had implemented CVD risk assessments. There were 8789 patients eligible for CVD risk evaluation (rheumatoid arthritis (RA), 4483; ankylosing spondylitis (AS), 1663; psoriatic arthritis (PsA), 1928; unspecified and other forms of spondyloarthropathies (SpA), 715) of whom 41.4 % received a CVD risk assessment (RA, 44.7%; AS, 43.4%; PsA, 36.3%; SpA, 30.6%). Considerable differences existed in the proportions of patients receiving CVD risk evaluations across the NOCAR centres.

Conclusion

Patients with IJD represent a patient group with a high CVD burden that seldom undergoes CVD risk assessments. The NOCAR project lifted the offer of CVD risk evaluation to over 40% in this high-risk patient population.

Coronary Artery Calcium Score: the "Mammogram" of the Heart?

PURPOSE OF REVIEW

To discuss the classic analogy of "coronary artery calcium (CAC) as a mammogram of the heart", by evaluating the conceptual strengths, weaknesses, opportunities, and threats of a potential cardiovascular disease (CVD) screening strategy using CAC in apparently healthy adults.

RECENT FINDINGS

CAC is typically used for further CVD risk assessment. CAC is also currently being used as a screening test in specific subgroups of individuals, particularly in some Asian countries. Although this has yielded valuable insights on the determinants and pathophysiology of CVD, whether this approach results in improved clinical outcomes compared to other assessment and management approaches is currently unclear. Although CAC and mammograms share a number of characteristics, there are also important conceptual differences. The evidence supporting CAC, which is a robust CVD risk assessment tool, for CVD screening purposes is currently very limited, and further research is needed.

Effect of physician characteristics and knowledge on the quality of dyslipidemia management and LDL-C target goal achievement in China: Subgroup analysis of the Dyslipidemia International Study

Objective

This study aimed to investigate the effect of physicians’ characteristics and knowledge of LDL–C target goals on the quality of lipid management in China.

Methods

A total of 25 317 dyslipidemia patients who had taken lipid–lowering medication for >3 months were enrolled in our study. Patients’ demographic data, medical history, lipid profile, their physician’s specialty and professional title and their hospital level as well as their LDL–C goal opinions were recorded.

Results

Questionnaires were completed by 926 physicians with 6 different specialties and 4 professional statuses, in 3 different–level hospitals. Most (74.5%) of the physicians recognized the importance of considering LDL–C serum concentration for treating dyslipidemia, and set target LDL–C goals according to the 2007 Chinese guidelines for 83.4% of their patients. The LDL–C goal achievement rate was significantly higher for patients whose physicians’ knowledge of LDL–C target goals was consistent with guideline recommendations, compared with those whose physicians’ knowledge was inconsistent with the guidelines (60.4% vs 31.1%, P < 0.0001). Physicians working in tier 1 (odds ration (OR) = 2.95; 95% CI 2.37–3.67), (OR = 1.56; 95% CI 1.34–1.81) and tier 2 (OR = 2.53; 95% CI 2.22–2.88), (OR = 1.16; 95% CI 1.06–1.27) hospitals, specialized in neurology (OR = 1.13; 95% CI 0.93–1.36), (OR = 1.57; 95% CI 1.40–1.77), internal medicine (OR = 1.07; 95% CI 0.90–1.27), (OR = 1.58; 95% CI 1.39–1.80), endocrinology (OR = 1.02; 95% CI 0.87–1.21), (OR = 1.63; 95% CI 1.47–1.82) and being a resident vs attending physician (OR = 1.05; 95% CI 0.92–1.20), (OR = 1.00; 95% CI 1.00–1.19) were independent risk factors for low knowledge of LDL–C target goals and low LDL–C goal achievement.

Conclusion

Chinese physicians’ characteristics and knowledge of LDL–C target goals were associated with patients’ LDL–C goal achievement.

Hypertension Survey in Italy: Novel Findings from the Campania Salute Network

The "Campania Salute" (CS) is a network system aimed at improving the management of essential hypertension by integrating the activity of general practitioners (GPs) with that of the hypertension specialists. It involves 23 outpatient hypertensive clinics distributed in different community hospitals of the Napoli's metropolitan area, 60 randomly selected GPs homogeneously distributed in the same area, and the Hypertension Clinic of the Federico II University in Naples (co-ordinating centre). Through the CS system it is possible to share clinical data collected during each visit at peripheral units (general practitioners and community hospitals hypertensive clinics), which manage low-risk hypertensive patients, and the co-ordinating centre, which mainly manages high-risk hypertensive patients. The co-ordinating centre works in co-operation with the peripheral units in the treatment and follow-up of all hypertensive patients. Since the first reports on the CS network activity, it has been evident the effectiveness of this network in ameliorating the clinical management of the hypertensive disease. CS network is also a large prospective registry that generated several scientific reports based on the longitudinal assessment of hypertensive patients during their treatment. Nowadays, as observed in the Health Search Database, the rate of BP control in Campania was 69.5%, almost reaching the "Objective 70%", a result that could be in part linked to the activity of the CS network.

Women's Heart Health: Knowledge, Beliefs, and Practices of Canadian Physicians

BACKGROUND

Heart disease is a leading cause of morbidity and mortality in women. To date, the majority of knowledge regarding heart disease is based on research conducted in men. As a result, a male-oriented model of heart disease constitutes the basis for diagnostic and therapeutic strategies for both sexes. This article reports findings from the first survey of Canadian physicians to examine their knowledge, beliefs, and practices regarding heart disease in women.

MATERIALS AND METHODS

This cross-sectional survey, adapted from an instrument used in the United States, was undertaken in the spring of 2015. A sample of 504 physicians from a randomly selected sample of online responses was produced.

RESULTS

Overall, physician responses demonstrate a general lack of awareness regarding the prevalence and approaches to the identification of, and treatments for, heart disease in women. In addition, physicians did not provide high ratings of their own effectiveness in supporting female patients to prevent or manage heart disease. The barriers that physicians face and the strategies to support them in improving women's heart health were explored.

CONCLUSIONS

There is a clear need to educate physicians about heart disease in women and its prevention and management. More female-specific research, prevention, and clinical programs will enhance our ability to significantly improve cardiovascular health in Canadian women.

Barriers to ESC guideline implementation: results of a survey from the European Council on Cardiovascular Nursing and Allied Professions (CCNAP)

Background:

The European Society of Cardiology (ESC) has a comprehensive clinical guideline development programme, relevant for all clinicians. However, implementation of guidelines is not always optimal.

Aim:

The aim of this study was to determine nurses’ and allied professionals’ awareness and barriers regarding clinical guideline implementation.

Methods:

A cross-sectional survey was administrated online and in print at EuroHeartCare 2015. A questionnaire was developed which examined awareness and barriers to implementation of ESC guidelines on cardiovascular disease prevention in clinical practice (2012) and ESC guidelines in general.

Results:

Of the 298 respondents, 12% reported that the prevention guidelines were used in their practice area. Respondents identified, in order of magnitude, that lack of leadership, workload, time, resources and a perception that they were unable to influence current practice were barriers to the use of the prevention guidelines. When asked to rank barriers to use of any ESC guidelines, time (22%) and leadership (23%) were ranked highest.

Conclusions:

Implementation of ESC guidelines by nurses, the majority responders in this survey, is a serious problem, requiring urgent improvement to ensure patients receive optimal evidence based care. Issues of leadership, workload, time and resources are significant barriers to guideline implementation. It is of concern that these professionals perceive both that they have little influence on implementation decisions and lack of leadership regarding guideline implementation. Educational and organisational strategies to improve leadership skills are imperative. These will build self-efficacy and empower nurses and allied professionals to advocate for evidence-based care in the clinical environment.