Increased knowledge makes a difference! - general practitioners' experiences of pictorial information about subclinical atherosclerosis for primary prevention: an interview study from the VIPVIZA trial

Improved adherence to statin treatment and differences in results between men and women after pictorial risk communication-a sub-study of the VIPVIZA RCT

BACKGROUND

People with intermediate CVD risk constitute most of the population. Within this group, the proportion of events is lower compared to the high-risk group, but they contribute with the largest absolute number of events. Atherosclerosis is a dynamic process and progression can be slowed or even reversed with medication and lifestyle changes, but adherence to prescribed treatment is crucial.

AIM

To investigate the long-term effects of interventions with pictorial risk communication of cardiovascular (CVD) risk on average adherence in a group of statin users. Compare response in adherence over time between men and women after intervention.

METHODS

Participants on active statin treatment were followed up to 5 years after being randomly assigned to an intervention program aimed at raising CVD risk awareness among participants and their physicians. Merging prescribed medication databases with VIPVIZA study to study adherence over time. A moving average adherence was used to compare groups.

RESULTS

Generally, the average adherence to statins among the 512 participants was high. Men had a higher average adherence over time, while women had a sharper increase in adherence in conjuncture with the intervention program.

CONCLUSIONS

Both men and women were receptive to pictorial information regarding CVD risk, but the intervention effect was more pronounced in women. Sex differences are important when considering risk communication strategies. Periodically repeating the intervention was beneficial for maintaining the intervention effect over time.

TRIAL REGISTRATION

The VIPVIZA study is registered with ClinicalTrials.gov , May 8, 2013, number NCT01849575.

Communicating cardiovascular risk: Systematic review of qualitative evidence

INTRODUCTION

Cardiovascular risk prediction models are widely used to help individuals understand risk and make decisions.

METHODS

Systematic review of qualitative evidence. We searched MEDLINE, Embase, PsycINFO and CINAHL. We included English-language qualitative studies on the communication of cardiovascular risk. We assessed study quality using Hawker et al.'s tool and synthesised data thematically.

RESULTS

Thirty-seven studies were included. Many patients think that risk scores are of limited practical value. Other sources of information feed into informal estimates of risk, which may lead patients to reject the results of clinical risk assessment when the two conflict. Clinicians identify a number of barriers to risk communication, including patients' limited understanding of risk and excessive anxiety. They use a range of strategies for adapting risk communication. Both clinicians and individuals express specific preferences for risk communication formats.

DISCUSSION

Ways of communicating risk that provide some comparison or reference point seem more promising. The broader context of communication around risk may be more important than the risk scoring instrument. Risk communication interventions, in practice, may be more about appeals to emotion than a rationalistic model of decision-making.

From risk communication about asymptomatic atherosclerosis to cognitive and emotional reactions and lifestyle modification

BACKGROUND

Non-adherence in the general population to preventive guidelines on cardiovascular disease calls for an interdisciplinary approach acknowledging psychological factors of relevance for risk communication and lifestyle modification. Evidence is building up regarding the advantage of sharing arterial imaging evidence of subclinical atherosclerosis with asymptomatic individuals, but there is limited understanding of how this relates to mechanisms of importance for behavioural change. Longitudinal studies on associations between patients' reactions and lifestyle modification are missing. The population-based randomized controlled trial VIPVIZA investigates the impact of pictorial information about subclinical atherosclerosis, added to traditional risk factor-based communication. The intervention includes a personalized, colour-coded and age-related risk communication strategy and a motivational conversation, and has been shown to reduce cardiovascular disease risk.

METHODS

In the present study we assessed cognitive and emotional reactions to the intervention, and how these reactions are associated to lifestyle modification. The participants' evaluation of the risk communication was assessed in the intervention group (n = 1749). Lifestyle modification was assessed with a lifestyle index based on physical activity, diet, smoking and alcohol consumption at baseline and after 3 years. Associations between cognitive and emotional response and lifestyle modification were tested with analyses of covariance in a subset of participants (n = 714-857).

RESULTS

The intervention increased understanding of personal CVD risk, the possibility to influence the risk, and how to influence the risk. Severity of atherosclerosis was associated with emotional reactions, but emotions of strong negative valence were uncommon. Cognitive response and emotional arousal evoked by the intervention were positively associated with lifestyle modification, whereas negative emotions in isolation were not. High level of cognitive response in combination with high level of emotional arousal was found to be most beneficial for lifestyle modification.

CONCLUSIONS

The results demonstrate the potential of communicating asymptomatic atherosclerosis with a pictorial, colour-coded and age-related strategy, also including a motivational conversation. Furthermore, the results show the importance of CVD risk communication evoking engagement, and that an interaction between cognitive and emotional reactions might be central for sustained lifestyle modification. Our results also indicate that, in an asymptomatic population, atherosclerosis screening may strengthen disease prevention and health promotion.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01849575. Registration date 08/05/2013.

Impact of Patient Visualization of Cardiovascular Images on Modification of Cardiovascular Risk Factors: Systematic Review and Meta-Analysis

BACKGROUND

It is unclear whether detection and patient visualization of cardiovascular (CV) images using computed tomography to assess coronary artery calcium or carotid ultrasound (CU) to identify plaque and intima-medial thickness merely prompts prescription of lipid-lowering therapy or whether it motivates lifestyle change among patients.

OBJECTIVES

This systematic review and meta-analysis sought to investigate whether patient visualization of CV images (computed tomography or CU) has a beneficial impact on improving overall absolute CV risk as well as lipid and nonlipid CV risk factors in asymptomatic individuals.

METHODS

The key words "CV imaging," "CV risk," "asymptomatic persons," "no known or diagnosed CV disease," and "atherosclerotic plaque" were searched in PubMed, Cochrane, and Embase in November 2021. Randomized trials that assessed the role of CV imaging in reducing CV risk in asymptomatic persons with no known CV disease were eligible for study inclusion. The primary outcome was a change in 10-year Framingham risk score from the trial commencement to the end of the follow-up following patient visualization of CV images.

RESULTS

Six randomized controlled trials (7,083 participants) were included; 4 studies used coronary artery calcium and 2 used CU to detect subclinical atherosclerosis. All studies used image visualization in the intervention group to communicate CV risk. Imaging-guidance was associated with a 0.91% improvement in 10-year Framingham risk score (95% CI: 0.24%-1.58%; P = 0.01). Significant reductions in low-density-lipoprotein, total cholesterol, and systolic blood pressure were observed (all P < 0.05).

CONCLUSIONS

Patient visualization of CV imaging is associated with overall CV risk reduction and improvement of individual risk factors: cholesterol and systolic blood pressure.

Effect of visual presentation of atherosclerotic carotid plaque on adherence to secondary preventive therapy using mHealth technologies (PreventiPlaque app): Study protocol for a randomized controlled trial

Background

Cardiovascular disease is the major cause of death worldwide. Although knowledge regarding diagnosing and treating cardiovascular disease has increased dramatically, secondary prevention remains insufficiently implemented due to failure among affected individuals to adhere to guideline recommendations. This has continued to lead to high morbidity and mortality rates. Involving patients in their healthcare and facilitating their active roles in their chronic disease management is an opportunity to meet the needs of the increasing number of cardiovascular patients. However, simple recall of advice regarding a more preventive lifestyle does not affect sustainable behavioral lifestyle changes. We investigate the effect of plaque visualization combined with low-threshold daily lifestyle tasks using the smartphone app PreventiPlaque to evaluate change in cardiovascular risk profile.

Methods

and study design: This randomized, controlled clinical trial includes 240 participants with ultrasound evidence of atherosclerotic plaque in one or both carotid arteries, defined as focal thickening of the vessel wall measuring 50% more than the regular vessel wall. A criterion for participation is access to a smartphone suitable for app usage. The participants are randomly assigned to an intervention or a control group. While both groups receive the standard of care, the intervention group has additional access to the PreventiPlaque app during the 12-month follow-up. The app includes daily tasks that promote a healthier lifestyle in the areas of smoking cessation, medication adherence, physical activity, and diet. The impact of plaque visualization and app use on the change in cardiovascular risk profile is assessed by SCORE2. Feasibility and effectiveness of the PreventiPlaque app are evaluated using standardized and validated measures for patient feedback.

Ethics and dissemination

This clinical trial is approved by the ethics committee of the University of Duisburg-Essen (Germany). Study results will be disseminated at conferences and in peer-reviewed journals. Information regarding the PreventiPlaque app is available via print media, social media channels, and on the authors' websites.

Cognitive and emotional reactions to pictorial-based risk communication on subclinical atherosclerosis: a qualitative study within the VIPVIZA trial

OBJECTIVES, SETTING AND SUBJECTS

Atherosclerosis screening with ultrasound is non-invasive and can be used as part of risk communication. The potential of personalised and pictorial-based risk communication is assessed in VIPVIZA, a population-based randomised controlled trial that aims at optimising cardiovascular disease (CVD) prevention by investigating the impact of visualisation of subclinical atherosclerosis. The present aim was to explore cognitive and emotional reactions evoked by the intervention as well as attitudes to any implemented life style changes in VIPVIZA participants in the intervention group with improved health status and furthermore to study possible interactions between these factors. Understanding mechanisms of action was central since non-adherence to preventive guidelines are often faced in clinical practice.

DESIGN

In-depth interviews with 14 individuals were analysed with qualitative content analysis.

RESULTS

Cognitive and emotional processes were highly interlinked and described by the main theme Cognitive and emotional reactions in strong interplay for orchestration of health oriented behavioural change. The informants' descriptions revealed two distinctly different psychological processes which constituted the two subthemes, Problem-focused coping and Encouragement-driven process.

CONCLUSIONS

The results highlight that an interaction between emotional reactions and efficacy beliefs is important in facilitating behavioural change. Furthermore, the results underscore the importance of the risk message being perceived as clear, accurate, reliable and also emotionally engaging and thereby show why atherosclerosis screening and pictorial-based risk communication have the potential to contribute to effective CVD prevention strategies and shared decision making in primary care. Trial registration: ClinicalTrials.gov identifier: NCT01849575, registration 8 May 2013.Key pointsAtherosclerosis screening and pictorial-based risk communication have the potential to contribute to more effective CVD prevention strategies.Risk messages on atherosclerosis status were perceived as clear, accurate, reliable and emotionally engaging.An interplay between efficacy beliefs and emotional reactions facilitated behavioural change.Patients' understanding of CVD risk is important for shared decision-making and of relevance for non-adherence to preventive guidelines.

Reduced progression of carotid intima media thickness by personalised pictorial presentation of subclinical atherosclerosis in VIPVIZA-A randomised controlled trial

OBJECTIVES

Reduced progression of atherosclerosis can decrease the risk of cardiovascular disease (CVD). This study aimed at evaluating the effect of a pictorial intervention showing atherosclerotic severity on the progression of carotid atherosclerosis.

METHODS

A prospective randomised open-label blinded end-point trial with participants aged 40-60 years enroled from a routine CVD prevention programme. The intervention group (n: 1575) and their treating physicians received an image based presentation of subclinical atherosclerotic severity measured by carotid ultrasound. The control group (n: 1579) did not receive any information about ultrasound results. Carotid ultrasound at baseline and at 3-year follow-up contained plaque detection and measurements of carotid intima media thickness (cIMT). The left, right and bilateral-mean-cIMT, plaque prevalence and total plaque area (TPA) at 3-year follow-up were compared between groups. Significance level was set to p = 0.01 to adjust for multiple comparisons.

RESULTS

The intervention group revealed reduced cIMT progression in the left-mean-cIMT of -0.011 mm (p = 0.001) compared with the control group. The intervention effect on cIMT progression was most prominent in individuals with increased cIMT and plaque prevalence at baseline (-0.021 mm, p = 0.005). There were no differences in progression between groups for the right-and bilateral-mean-cIMT (-0.005 mm, p = 0.223 and -0.005 mm, p = 0.036, respectively), nor any differences between groups for plaque prevalence or TPA (odds ratio 0.88, p = 0.09 and 0.89, p = 0.21, respectively).

CONCLUSION

Pictorial presentation of subclinical atherosclerotic severity sent to both the individual and their treating physician resulted in significantly reduced left cIMT progression. Pictorial presentation has the potential to increase adherence in CVD prevention.

Time to initiation of lipid-lowering drugs for subclinical atherosclerosis: sub-study of VIPVIZA randomized controlled trial, with single-arm cross-over

Aims

Visual information about subclinical atherosclerosis was provided to physicians and participants in the VIPVIZA trial, inclusion 2013–16 in northern Sweden, aiming to improve adherence to cardiovascular disease (CVD) prevention guidelines. Pictorial risk information may be more actionable. The aim of this study was to investigate the effect of intervention with pictorial risk information on time to first dispensing of statins.

Methods and results

Asymptomatic atherosclerotic disease was screened for by carotid ultrasound examination in 3532 participants enrolled in VIPVIZA, of those 3000 met the criteria for this study. Participants were randomly assigned to receive pictorial risk information consisting of graphical representation of atherosclerosis as compared to a control group without intervention. Time to initiation of statins was assessed during 5 years of follow-up through the National prescribed drug register. After 3 years, both groups were re-examined and received the intervention information. In the intervention group, initiation of statins increased considerably for the first 3 years and a smaller increase was also seen after re-intervention. After the cross-over, the control group showed a sharp increase in initiation of statins, almost reaching the same proportion treated at 5 years. The propensity to initiate statin treatment increased over the study period and there was no difference between men and women.

Conclusions

The pictorial information had an effect on time to initiation of statins, both as original and repeated intervention and also in the control group after single-arm cross-over. The current study supports pictorial information as a tool to shorten time to initiation of statins for CVD prevention.

The VIPVIZA study is registered with ClinicalTrials.gov, number NCT01849575.

The beneficial effect over 3 years by pictorial information to patients and their physician about subclinical atherosclerosis and cardiovascular risk: Results from the VIPVIZA randomized clinical trial

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VIPVIZA is a pragmatic randomized controlled trial performed within the regular primary health care and targeting both individuals and physicians.

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Beneficial effects on risk for cardiovascular disease regardless of sex and education level 3 years after providing pictorial information of subclinical atherosclerosis in addition to regular preventive information.

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The results indicate that the intervention effect is a combined effect of pharmacological treatment and lifestyle modification.

•

The intervention effect was observed in the intermediate risk group, the group where most CVD events occur and in which sufficient prevention is often overlooked.

Objective

Non-adherence to guidelines and preventive measures is a major challenge, particularly so to obtain long-term adherence to lifestyle changes and recommended medication. The objective was to investigate if pictorial information regarding subclinical carotid atherosclerosis provided to individuals and physicians gave sustained effects on cardiovascular risk beyond the previously reported effect after 1 year and up to 3 years.

Methods

A Prospective Randomized Open Blinded End-point (PROBE) trial. Within a CVD prevention program in Västerbotten County, Sweden, 3532 healthy individuals aged 40, 50 or 60 years were enrolled and 1:1 randomized to intervention (n = 1749; pictorial information with additional prevention materials to participants and physicians) or control group (n = 1783; no pictorial information to participants and physicians). Preventive measures were managed within primary care. Participants were investigated at baseline during 2013–2016 and at follow-up after 1 and 3 years.

Results

A beneficial effect on cardiovascular risk was observed at 3-year follow-up; Framingham Risk Score (FRS) was 13.38 for the intervention group and 14.08 for the control group (p = 0.047) and SCORE was 1.69 vs. 1.82 (p = 0.022). The effect observed at 1-year was sustained over 3 years after adjustment for sex and education and more pronounced among participants with a severe atherosclerotic picture at baseline.

Conclusions

This study provides evidence of sustained beneficial effects on the adherence to prevention guidelines over 3 years of pictorial information about subclinical carotid atherosclerosis, resulting in lower cardiovascular risk regardless of sex and educational level. Direct visualization of the underlying still subclinical atherosclerotic disease, rather than just indirect information about risk factors and statistical risk of future myocardial infarction, stroke and death, is one way to tackle the problem of non-adherence to prevention of cardiovascular diseases.