EUROASPIRE III. Management of cardiovascular risk factors in asymptomatic high-risk patients in general practice: cross-sectional survey in 12 European countries

Stepwise treatment of uncontrolled HyperTensioN (Stepwise-HTN): Study design of a cluster randomised controlled trial in primary care

BACKGROUND

Uncontrolled hypertension is a major health problem, and a key risk factor for cardiovascular disease. Most patients are detected and managed in primary care, but approximately 50% remains uncontrolled. Our aim is to assess whether a guided stepwise work-up management strategy for patients with uncontrolled hypertension in primary care would result in better blood pressure control in these patients compared to usual care.

METHODS

A cluster randomised controlled trial aiming at randomizing 40 general practices to either "a protocolised stepwise work-up" or to "usual care". Uncontrolled hypertension is defined as an office blood pressure (BP) >140/90 mmHg while being prescribed three or more antihypertensive drugs simultaneously from different therapeutic classes for three or more months in an adequate dose. In the intervention arm, patients with uncontrolled hypertension will receive the stepwise approach, consisting of (i) excluding a white coat effect, (ii) re-evaluation of lifestyle, (iii) re-evaluation of drug adherence, (iv) optimalisation of antihypertensive treatment and (v) referral if the office BP is still >140/90 mmHg. The control group receives usual care in a regular program for cardiovascular risk management. The primary outcome is the absolute difference in the mean 24-h systolic BP between intervention and control arm after 8 months. Secondary outcomes include differences in the percentage of patients achieving a controlled BP, and time to reach a controlled BP.

CONCLUSION

If stepwise treatment of uncontrolled hypertension is proven effective, the strategy could be implemented by blending the approach to the cardiovascular risk management already applied in general practice. Trial registration NTR7304, https://www.trialregister.nl/trial/7099.

Development of a multi-component tobacco cessation training package utilizing multiple approaches of intervention development for health care providers and patients attending non-communicable disease clinics of Punjab, India

Background

Providing patients with personalized tobacco cessation counseling that is culturally sensitive, and disease-specific from healthcare providers (HCPs) as part of their routine consultations is an approach that could be incorporated, using existing healthcare systems such as the Non-Communicable Disease (NCD) clinics. This paper describes the development of a multi-component culturally tailored, patient-centric, disease-specific tobacco cessation package utilizing multiple approaches of intervention development for healthcare providers and patients attending these clinics in Punjab, India, along with a proposed framework for implementation.

Methods

The proposed intervention package was developed in 6 stages. These included a review of literature for identifying successful cessation interventions for ethnic minority groups, co-production of the package with all stakeholders involved via a series of consultative meetings and workshops, understanding contextual factors of the state and 'factor-in' these in the package, pre-test of the package among HCPs and tobacco users using in-depth interviews, micro detailing and expansion of the package by drawing on existing theories of the Cascade Model and Trans-Theoretical Model and developing an evolving analysis plan through real-world implementation at two pilot districts by undertaking a randomized controlled trial, assessing implementer's experiences using a mixed-method with a primary focus on qualitative and economic evaluation of intervention package.

Results

A multi-component package consisting of a booklet (for HCPs), disease-specific pamphlets and short text messages (for patients; bilingual), and an implementation framework was developed using the 6-step process. A major finding from the in-depth interviews was the need for a specific capacity-building training program on tobacco cessation. Therefore, using this as an opportunity, we trained the in-service human resource and associated program managers at the state and district-level training workshops. Based on the feedback, training objectives were set and supported with copies of intervention package components. In addition, the role and function of each stakeholder were defined in the proposed framework.

Conclusion

Consideration of tobacco users' socio-cultural and patient-centric approach makes a robust strategy while developing and implementing an intervention providing an enlarged scope to improve care services for diversified socio-cultural communities.

Screening and health education practices related to cardiovascular risk factors among adults: results of a households survey in Sousse, Tunisia

In Tunisia, despite the implementation of national strategies to prevent some of cardiovascular risk factors, these diseases still represent the leading cause of death. The current study aimed to determine the prevalence of cardiovascular risk factors and assess the screening and health education practices related to these factors among the adults of Sousse (Tunisia). A cross-sectional study was conducted in 1000 households in Sousse, Tunisia. To collect data, a team of trained medical doctors administered by interview a pre-tested questionnaire and performed blood pressure and anthropometric measures at the participants' homes. In total, 1977 adults participated in the study. Their mean age was 39.8 (± 13.8) years. The Females/Males sex ratio was 1.5. Weight excess and lack of physical activity were found in 65.4% and 60.7% of participants. Screening for obesity and android obesity were reported by 36.6% and 5.7% of health services users. Advices from a healthcare professional to practice the recommended physical activity and eat healthily were reported by less than a third of these latter. Screening and health education practices related to cardiovascular risk factors should be reinforced in the Tunisian healthcare facilities. The implementation of multisectoral actions is necessary at the national level in order to obtain an environment that promotes a healthy lifestyle.

[Cardiovascular preventive recommendations. PAPPS 2022 thematic updates. Working groups of the PAPPS]

The recommendations of the semFYC's Program for Preventive Activities and Health Promotion (PAPPS) for the prevention of cardiovascular diseases (CVD) are presented. The following sections are included: epidemiological review, where the current morbidity and mortality of CVD in Spain and its evolution as well as the main risk factors are described; cardiovascular (CV) risk and recommendations for the calculation of CV risk; main risk factors such as arterial hypertension, dyslipidemia and diabetes mellitus, describing the method for their diagnosis, therapeutic objectives and recommendations for lifestyle measures and pharmacological treatment; indications for antiplatelet therapy, and recommendations for screening of atrial fibrillation, and recommendations for management of chronic conditions. The quality of testing and the strength of the recommendation are included in the main recommendations.

Subclinical Vascular Damage: Current Insights and Future Potential

The cardiovascular risk assessment must be carried out during all the different phases of life because the cardiovascular risk and the related prevention actions are dynamic and constantly evolving. As patients age, they change their exposure to various risk factors and accumulate comorbidities by changing their subjective cardiovascular risk, so it is necessary to undertake personalized early and preventive diagnostic actions. The main approach to asymptomatic vascular disease is based on primary prevention with the adoption of a healthy lifestyle. Indeed, lifestyle influences most of the traditional risk factors. In recent years, important differences between the sexes regarding cardiovascular risk factors have emerged and in particular, risk factors specific for female sex have been identified. Women are more likely to be categorized into lower risk categories for cardiovascular disease and, as a result, receive less lifestyle counseling than men, as well as less intensive prevention. This narrative review aims to analyze CVD risk prevention in asymptomatic atherosclerosis with a look at new emerging factors. In the end, we quickly analyzed the effects of the recent pandemic on lifestyle and cardiovascular risk and the potential negative effects in the long term.

Low-dose rivaroxaban plus aspirin in patients with polypharmacy and multimorbidity: an analysis from the COMPASS trial

BACKGROUND

In patients with coronary or peripheral arterial disease, adding low dose rivaroxaban to aspirin reduces cardiovascular events and mortality. Polypharmacy and multimorbidity are frequent in such patients.

AIMS

To analyze whether the benefits and risks of rivaroxaban plus aspirin varies in patients with comorbidities and receiving multiple drugs.

METHODS AND RESULTS

We describe ischemic events (cardiovascular death, stroke, or myocardial infarction) and major bleeding in participants from the randomised, double-blind COMPASS study by number of cardiovascular medications and concomitant medical conditions. We compared event rates and hazard ratios (HR) for rivaroxaban plus aspirin versus aspirin alone by the number of medications and concomitant conditions, and tested for interaction between polypharmacy or multimorbidity and the antithrombotic regimen.The risk of ischemic events was higher in patients with more concomitant drugs (HR 1.7, 95%CI 1.5-2.1 for >4 vs 0-2) and with more comorbidities (HR 2.3, 1.8-2.1 for >3 vs 0-1). Multimorbidity, but not polypharmacy, was associated with a higher risk of major bleeding. The relative efficacy, safety, and net clinical benefit of rivaroxaban were not affected by the number of drugs or comorbidities. Patients taking more concomitant medications derived the largest absolute reduction in the net clinical outcome with added rivaroxaban (1.1% vs 0.4% reduction with >4 vs 0-2 cardiovascular drugs, NNT 91 vs 250).

CONCLUSION

Adding low-dose rivaroxaban to aspirin resulted in benefits irrespective of the number of concomitant drugs or comorbidities. Multiple comorbidities and/or polypharmacy should not dissuade the addition of rivaroxaban to aspirin in otherwise eligible patients.

[Cardiovascular preventive recommendations. PAPPS 2020 update]

The recommendations of the semFYC's Program for Preventive Activities and Health Promotion (PAPPS) for the prevention of cardiovascular diseases (CVD) are presented. The following sections are included: Epidemiological review, where the current morbidity and mortality of CVD in Spain and its evolution as well as the main risk factors are described; Cardiovascular (CV) risk tables and recommendations for the calculation of CV risk; Main risk factors such as arterial hypertension, dyslipidemia and diabetes mellitus, describing the method for their diagnosis, therapeutic objectives and recommendations for lifestyle measures and pharmacological treatment; Indications for antiplatelet therapy, and recommendations for screening of atrial fibrillation. The quality of testing and the strength of the recommendation are included in the main recommendations.

Care management of patients with high cardiovascular risk in Hungary an international and Hungarian longitudinal comparison of target level achievement

Background

Patients with high cardiovascular risk are usually cared for in primary care settings. Assessment of the effectiveness of long-time care was a subject of many European studies in the last two decades. This paper aims to present two Hungarian primary care cross sectional surveys and to compare their results to the primary care arms of the European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) III. and IV. studies.

Methods

Between 2010 and 2011, 679 patients with high cardiovascular risk were recruited in 20 Hungarian primary care practices and 628 patients were selected in 40 practices between 2015 and 2016. The actual national recommendations were used for classification, all based on European guidelines. Achievements of target levels for blood pressure, total-, LDL-and HDL-cholesterols, triglyceride, and HbA_1c (in diabetics) were recorded and analyzed. Further cardiovascular risk factors, such as smoking, BMI, waist-circumference were also evaluated.

Results

There was a statistically significant improvement in the management of blood-pressure and plasma LDL-cholesterol levels among high risk patients, while there was no change in the plasma triglyceride values. The effectiveness of diabetes care deteriorated. In international relation, the management of blood pressure and plasma LDL-cholesterol values were better in Hungary when compared to the results of EUROASPIRE III-IV. studies, while the previous advantage in diabetes care disappeared. A higher proportion of diabetic patients was above the target values in Hungary than the means of the European surveys. There was a higher proportion of smokers in the Hungarian samples, while the proportion of obese and overweight patients was similar to the European sample.

Conclusions

Primary care has a unique role in cardiovascular prevention. Although many of the patients are managed appropriately, there is a need to improve primary care services in Hungary, giving more competences to GPs in prescription and introducing structural changes in the healthcare system.

Cardiovascular risk factor control in British adults with diabetes mellitus: Retrospective cohort study

Using primary care electronic medical records (the United Kingdom Health Improvement Network Database 2003-2015), we examined the control of cardiovascular risk factors in the first year after diagnosis in British adults with diabetes mellitus. Among 292 170 individuals with diabetes receiving frequent outpatient management (median of 16 primary care visits in the prior year), control of cardiovascular risk factors a median of 354 days after diagnosis was suboptimal: 14.7% had HbA1C < 7%, SBP < 140 mm Hg, LDL cholesterol ≤1.8 mmol/L or taking a statin, and were nonsmokers (the proportion dropped to 7.5% if the SBP target was defined as <130 mm Hg). While 90.4% had an LDL cholesterol ≤1.8 mmol/L or were taking a statin, and 86.0% were nonsmokers, only 52.0% had HbA1C < 7% and 53.1% had SBP < 140 mm Hg (29.8% had SBP < 130 mm Hg) despite 71.4% taking antihypertensive agents. Thus, there is still a need for quality improvement strategies that target all atherosclerotic risk factors in individuals with diabetes and not just glycaemic control.

Primary prevention efforts are poorly developed in people at high cardiovascular risk: A report from the European Society of Cardiology EURObservational Research Programme EUROASPIRE V survey in 16 European countries

BACKGROUND

European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) V in primary care was carried out by the European Society of Cardiology EURObservational Research Programme in 2016-2018. The main objective was to determine whether the 2016 Joint European Societies' guidelines on cardiovascular disease prevention in people at high cardiovascular risk have been implemented in clinical practice.

METHODS

The method used was a cross-stional survey in 78 centres from 16 European countries. Patients without a history of atherosclerotic cardiovascular disease either started on blood pressure and/or lipid and/or glucose lowering treatments were identified and interviewed ≥ 6 months after the start of medication.

RESULTS

A total of 3562 medical records were reviewed and 2759 patients (57.6% women; mean age 59.0 ± 11.6 years) interviewed (interview rate 70.0%). The risk factor control was poor with 18.1% of patients being smokers, 43.5% obese (body mass index ≥30 kg/m2) and 63.8% centrally obese (waist circumference ≥88 cm for women, ≥102 cm for men). Of patients on blood pressure lowering medication 47.0% reached the target of <140/90 mm Hg (<140/85 mm Hg in people with diabetes). Among treated dyslipidaemic patients only 46.9% attained low density lipoprotein-cholesterol target of <2.6 mmol/l. Among people treated for type 2 diabetes mellitus, 65.2% achieved the HbA1c target of <7.0%.

CONCLUSION

The primary care arm of the EUROASPIRE V survey revealed that large proportions of people at high cardiovascular disease risk have unhealthy lifestyles and inadequate control of blood pressure, lipids and diabetes. Thus, the potential to reduce the risk of future cardiovascular disease throughout Europe by improved preventive cardiology programmes is substantial.

Cardiovascular risk factors among high-risk individuals attending the general practice at king Abdulaziz University hospital: a cross-sectional study

Background

Cardiovascular disease (CVD) is the primary cause of death worldwide, accounting for 31.0% of all deaths and more than 18 million deaths annually. The 2008 World Health Report indicated that 144 (35%) of the 413 deaths per 100,000 in 2002 in the Kingdom of Saudi Arabia (KSA) were due to CVD. Primary prevention is an important focus of most of the cardiovascular prevention guidelines around the world. In this study, we aimed to describe the prevalence of extrinsic risk factors for CVDs in a high-risk population attending general practice in Jeddah, KSA.

Methods

We conducted a cross-sectional survey at King Abdulaziz University Hospital in Jeddah. Patients started on lipid-lowering and/or antihypertensive and/or antidiabetes treatments without a history of established cardiovascular disease were interviewed. The questionnaire was adopted from the EUROASPIRE III study.

Results

Two hundred and fifty high-risk individuals (80.0% female) were interviewed. Overall, 72% of the patients had been diagnosed with hypertension, 61.2% of patients had dyslipidemia, and approximately two-thirds of patients had diabetes mellitus. Most of the patients (88%) were non-smokers. The mean waist circumference of patients was 101.6 ± 14.1 cm, which suggests most were clinically obese. About 54.8% of the patients followed an unhealthy diet and 52.0% were physically inactive. There were significant differences between women and men in relation to dyslipidemia (p = 0.007), unhealthy diet (p = 0.034), being overweight (p = 0.018), and high blood cholesterol (p = 0.002). We observed significantly greater prevalence of hypertension (p = 0.073), unhealthy diet (p = 0.015), being overweight (p = 0.018), and high blood cholesterol (p = 0.000) in those patients with dyslipidemia.

Conclusion

Our study presents novel findings in the KSA. Women were more likely to have high-risk CVD risk factors compared with their male counterparts in this sample. Gender-specific prevention programs in the KSA should be considered to more appropriately target at-risk individuals, to reduce preventable morbidity and mortality associated with CVDs.

Management of atherogenic dyslipidemia in the primary care setting in Spain

AIM

To describe the management of atherogenic dyslipidemia (AD) in routine clinical practice in the Primary Care (PC) setting in Spain.

METHODS

Observational, descriptive, cross-sectional study based on a structured questionnaire designed for this study and addressed to PC physicians. The questionnaire content was based on a literature review and was validated by 3 experts in AD.

RESULTS

A total of 1029 PC physicians participated in the study. 96.99% indicated that AD is determinant for cardiovascular risk, even if LDL-C levels are appropriate. 88.43% evaluated residual cardiovascular risk in their clinical practice, however, only 27.89% of them evaluated it in secondary prevention. Regarding diagnosis, 82.22% reported that TC, TG, HDL-C and non-HDL-C are essential measures when evaluating AD. Almost all physicians reported that they can request fractionated cholesterol to assess HDL-C and LDL-C, however 3.69% could not. Physicians (95.63%) considered that the first step in AD treatment should be diet, regular exercise, smoking cessation and pharmaceutical treatment, if necessary. 19.1% agreed partially or completely that gemfibrozil is the most suitable fibrate to associate with statins. 74.83% completely agreed that fenofibrate is the most suitable fibrate to combine with statins.

CONCLUSIONS

Physicians have access to general Spanish guidelines and recommendations associated with AD management, however, it is necessary to continue rising awareness about the importance of early detection and optimal control of AD to reduce patients' cardiovascular risk.

Do compensatory health beliefs predict behavioural intention in a multiple health behaviour change context? Evidence in individuals with cardiovascular diseases?

Multiple health behaviour change (MHBC) represents one of the best ways to prevent reoccurrence of cardiovascular events. However, few individuals with cardiovascular diseases engage in this process. The present study examined the role of compensatory health beliefs (CHB; i.e., belief that a healthy behaviour compensates an unhealthy one) as a drag to engagement in this process. Some studies have shown that CHBs predict intention to engage in healthy behaviours, but no study has investigated CHBs in individuals who actually need to change multiple health behaviours. The goal was to better understand the role of CHBs in intentions formation process among individuals with cardiac diseases in an MHBC context. One hundred and four patients completed a questionnaire at the beginning of their cardiac rehabilitation program. Results showed that: (1) CHBs negatively predicted intentions (2) but only for participants with high self-efficacy or low risk perception; (3) CHBs predictions differed depending on the nature of the compensating behaviour, and were more predictive when medication intake was the compensating one. Findings only partially confirmed previous research conducted on healthy individuals who were not in an MHBC process, and emphasized the importance of considering CHBs for individuals in this process.

The prevalence and related factors of familial hypercholesterolemia in rural population of China using Chinese modified Dutch Lipid Clinic Network definition

Background

Familial hypercholesterolemia (FH) is a common monogenic disease, while studies about the epidemiology for the general population in China was scarce. Aim of the study was to estimate the prevalence of FH and explore related factors by the Chinese modified Dutch Lipid Clinic Network (DLCN) definition.

Methods

A total of 39,205 participants (15,463 males and 23,742 females) aged 18–79 years old were enrolled from the Henan Rural Cohort Study. FH was defined by the Chinese modified DLCN definition, and score > 5 was classified as FH. Logistic regression analysis was used to calculate the odds ratio and 95% confidence interval.

Results

Crude prevalence of probable/definite FH was 0.35% (0.29–0.41%), estimated by the Chinese modified DLCN definition. Prevalence in female was 0.38%, and in male, it was 0.32%. Age-standardized prevalence in female increased significantly around the age of 50 years. Moreover, there were no FH patients getting low-density lipoprotein cholesterol controlled to the recommended level. Multivariate logistic regression identified that older, overweight/obesity were positively associated with FH.

Conclusions

The current study indicated that FH was not rare in rural area of China (1 in 286). Effective early detection and timely control of FH must be strengthened to reduce disease burden.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7212-4) contains supplementary material, which is available to authorized users.

Impact of text messages in a middle-income country to promote secondary prevention after acute coronary syndrome (IMPACS): A randomized trial

BACKGROUND

Studies that used short message service (SMS) programs as an intervention to promote health care have shown beneficial results in the control of risk factors for ischemic heart disease in patients of high-income countries, but evidence is lacking in low or middle-income countries.

AIMS

The purpose of this study is to evaluate whether the use of SMS increases risk factor control within 6 months after discharge by acute coronary syndrome (ACS) in a middle-income country.

METHODS

It will be a 2-arm, parallel, double-blind, randomized clinical trial of 160 patients discharged after an ACS from a single center with 6 months of follow-up. The intervention group will receive 4 SMS per week offering advice, motivation and information about medication adherence, increase of regular physical activity, adoption of healthy dietary measures, and smoking cessation (if appropriate). The primary outcome is achieving 4 or 5 points in a risk factor control score, which combines the cluster effect of 5 main modifiable risk factors for ACS [low-density lipoprotein cholesterol, LDL-C <70 mg/dL, blood pressure <140/90 mm Hg, regular exercise (≥5 days/week × 30 minutes of moderate exercise per session), nonsmoker status, and body mass index, BMI <25 kg/m]. Secondary outcomes are plasma LDL-C level, level of physical activity, blood pressure, medication adherence, proportion of nonsmokers, BMI, rehospitalization, cardiovascular death, and death from any cause. This study, as a randomized clinical trial protocol, followed the recommendations of the Standard Protocol Items (SPIRIT).

EXPECTED OUTCOMES

This study aims to provide evidence of whether SMS interventions are effective in improving cardiovascular disease risk factors control in post-ACS patients in a middle-income country. CLINICALTRIALS.

GOV IDENTIFIER

NCT03414190 (First posted on January 29, 2018; last update on May 14, 2018) - Retrospectively registered.

Free-Living Humans Cross Cardiovascular Disease Risk Categories Due to Daily Rhythms in Cholesterol and Triglycerides

Cardiovascular disease risk assessment relies on single time-point measurement of risk factors. Although significant daily rhythmicity of some risk factors (e.g., blood pressure and blood glucose) suggests that carefully timed samples or biomarker timeseries could improve risk assessment, such rhythmicity in lipid risk factors is not well understood in free-living humans. As recent advances in at-home blood testing permit lipid data to be frequently and reliably self-collected during daily life, we hypothesized that total cholesterol, HDL-cholesterol or triglycerides would show significant time-of-day variability under everyday conditions. To address this hypothesis, we worked with data collected by 20 self-trackers during personal projects. The dataset consisted of 1,319 samples of total cholesterol, HDL-cholesterol and triglycerides, and comprised timeseries illustrating intra and inter-day variability. All individuals crossed at least one risk category in at least one output within a single day. 90% of fasted individuals (n = 12) crossed at least one risk category in one output during the morning hours alone (06:00-08:00) across days. Both individuals and the aggregated group show significant, rhythmic change by time of day in total cholesterol and triglycerides, but not HDL-cholesterol. Two individuals collected additional data sufficient to illustrate ultradian (hourly) fluctuation in triglycerides, and total cholesterol fluctuation across the menstrual cycle. Short-term variability of sufficient amplitude to affect diagnosis appears common. We conclude that cardiovascular risk assessment may be augmented via further research into the temporal dynamics of lipids. Some variability can be accounted for by a daily rhythm, but ultradian and menstrual rhythms likely contribute additional variance.

Physicians' lifestyle advice on primary and secondary cardiovascular disease prevention in Germany: A comparison between the STAAB cohort study and the German subset of EUROASPIRE IV

Background

We assessed prevalence and determinants in appropriate physician-led lifestyle advice (PLA) in a population-based sample of individuals without cardiovascular disease (CVD) compared with a sample of CVD patients.

Methods

PLA was assessed via questionnaire in a subsample of the population-based Characteristics and Course of Heart Failure Stages A-B and Determinants of Progression (STAAB) cohort free of CVD (primary prevention sample) and the German subset of the fourth EUROASPIRE survey (EUROASPIRE-IV) comprising CVD patients (secondary prevention sample). PLA was fulfilled if the participant reported having ever been told by a physician to: stop smoking (current/former smokers), reduce weight (overweight/obese participants), increase physical activity (physically inactive participants) or keep to a healthy diet (all participants). Factors associated with receiving at least 50% of the PLA were identified using logistic regression.

Results

Information on PLA was available in 665 STAAB participants (55 ± 11; 55% females) and in 536 EUROASPIRE-IV patients (67 ± 9; 18% females). Except for smoking, appropriate PLA was more frequently given in the secondary compared with the primary prevention sample. Determinants associated with appropriate PLA in primary prevention were: diabetes mellitus (odds ratio (OR) 4.54; 95% confidence interval (CI) 1.88–10.95), hyperlipidaemia (OR 3.12; 95% CI 2.06–4.73) and hypertension (OR 1.74; 95% CI 1.15–2.62); in secondary prevention: age (OR per year 0.96; 95% CI 0.93–0.98) and diabetes mellitus (OR 2.33; 95% CI 1.20–4.54).

Conclusions

In primary prevention, PLA was mainly determined by the presence of vascular risk factors, whereas in secondary prevention the level of PLA was higher in general, but the association between CVD risk factors and PLA was less pronounced.

ITM support for patients with chronic respiratory and cardiovascular diseases: a protocol for a randomised controlled trial

INTRODUCTION

Simple and scalable strategies are needed to improve 'out-of-hospital' support and management for people living with cardiovascular disease (CVD) and respiratory disease. Text messaging via mobile phones has been shown to be effective in helping promote lifestyle change and is supported by quantitative and qualitative evidence. The aim of this study is to test the effectiveness and implementation of a 6-month text messaging support programme for people with CVD and respiratory disease as an addition to cardiac and pulmonary outpatient rehabilitation.

METHODS AND ANALYSIS

Pragmatic randomised controlled trial (n=310) to test the effectiveness of a 6-month text message support programme on clinical outcomes in people with CVD and chronic respiratory disease who are attending outpatient cardiac and pulmonary rehabilitation. The study includes a nested process evaluation to inform scalability and implementation across settings. The intervention group will receive a text message support programme comprising five messages per week for 26 weeks and the control group will continue with standard care. The primary outcome is exercise capacity (6 min walk distance). Secondary outcomes include clinical measures (proportion of people meeting the Australian guideline-recommended blood pressure and cholesterol targets), lifestyle outcomes (smoking rates, achievement of national guidelines for nutrition and physical activity), quality of life, mood (Hospital Anxiety and Depression Scale), medication adherence and attendance at and completion of rehabilitation.

ETHICS AND DISSEMINATION

Primary ethics approval was received from the Sydney Local Health District Hospital Human Research Ethics Committee and associated Governance committees at sites. Results will be disseminated via the usual scientific forums including peer-reviewed publications and presentations at international conferences. At its conclusion, the study will determine the effectiveness and implementation of a simple programme that aims to improve health outcomes and attendance at rehabilitation for people with CVD and chronic respiratory disease.

TRIAL REGISTRATION NUMBER

ACTRN12616001167459.

Secondary prevention therapies in acute coronary syndrome and relation to outcomes: observational study

Objective

To ascertain the use of secondary prevention medications and cardiac rehabilitation after an acute coronary syndrome (ACS) and the impact on 2-year outcomes.

Methods

CONCORDANCE (Cooperative National Registry of Acute Coronary care, Guideline Adherence and Clinical Events) is a prospective, observational registry of 41 Australian hospitals. A representative sample of 6859 patients with an ACS and 6 months’ follow-up on 31 May 2016 were included. The main outcome measure was use of ≥75% of indicated medications (≥4/5 (or ≥3/4 if contraindicated) of angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker, beta-blocker, lipid-lowering therapy, aspirin and other antiplatelet). Major adverse cardiovascular events (MACE) included myocardial infarction, stroke or cardiovascular death.

Results

The mean age was 65±13 years, 29% were women, and the mean Global Registry of Acute Coronary Events (GRACE) score was 106±30. At discharge, 92% were on aspirin, 93% lipid-lowering therapy, 78% beta-blocker, 74% ACE/angiotensin receptor blocker and 73% a second antiplatelet; 89% were taking ≥75% of medications at discharge, 78% at 6 months and 66% at 2 years. At 6 months, 38% attended cardiac rehabilitation, 58% received dietary advice and 32% of smokers reported quitting. Among 1896 patients followed to 2 years, death/MACE was less frequent among patients on ≥75% vs <75% of medications (8.3% vs 13.9%; adjusted OR 0.75, 95 % CI 0.56 to 0.99), and was less frequent in patients who attended versus who did not attend cardiac rehabilitation (4.6% vs 13.4%; adjusted OR 0.44, 95% CI 0.31 to 0.62).

Conclusions

Use of secondary prevention therapies diminishes over time following an ACS. Patients receiving secondary prevention had decreased rates of death and MACE at 2 years.

Prevalence of dyslipidemia and its association with cardiometabolic factors and kidney function in the adult Romanian population: The PREDATORR study

The aims were to assess the prevalence and characteristics of dyslipidemia phenotypes in a Romanian population-based sample from the PREDATORR study.

METHODS

PREDATORR was an epidemiological study with a cross-sectional, cluster random sampling design. Participants were classified into four dyslipidemia phenotypes based on the NCEP ATP III criteria: isolated hypertrigliceridemia, isolated hypoHDL-C, isolated hyperLDL-C and mixed dyslipidemia (≥2 standard lipid abnormalities). Overall, 2656 were included in the analysis by dyslipidemia phenotypes.

RESULTS

An estimated 67.1% of Romanian adults have at least one lipid abnormality: 27.5% (95%CI26.0-28.9%) have elevated TG, 29.4% (95%CI27.9-30.8%) have low HDL-C and 47.8% (95%CI46.3-49.2%) have elevated LDL-C (26.2% had LDL-C levels ≥2.58 mmol/l associated with CHD or CHD risk equivalent). Also, 30% Romanian adults have mixed dyslipidemia with 7.6% (95%CI6.1-9.0%) having all three lipid abnormalities. THE AGE: and sex-adjusted prevalence of isolated dyslipidemia phenotypes in Romanian adult population was 23.7% (95%CI22.2-25.1%) for hyperLDL-Cholesterolemia, 9.3% (95%CI7.8-10.7%) for hypoHDL-Cholesterolemia and 4.1% (95%CI2.6-5.5%) for hypertriglyceridemia. Among participants with triglycerides ≥2.25 mmol/l, 15.2% (95%CI13.7-16.6%) of Romanian adults have non-HDL-C levels ≥3.36 mmol/l.

CONCLUSIONS

The PREDATORR survey indicated a high prevalence of dyslipidemia phenotypes in the Romanian population aged 20-79 years, providing data on its association with several cardiometabolic risk factors.

Action Plan for Stroke in Europe 2018-2030

Two previous pan-European consensus meetings, the 1995 and 2006 Helsingborg meetings, were convened to review the scientific evidence and the state of current services to identify priorities for research and development and to set targets for the development of stroke care for the decade to follow. Adhering to the same format, the European Stroke Organisation (ESO) prepared a European Stroke Action Plan (ESAP) for the years 2018 to 2030, in cooperation with the Stroke Alliance for Europe (SAFE). The ESAP included seven domains: primary prevention, organisation of stroke services, management of acute stroke, secondary prevention, rehabilitation, evaluation of stroke outcome and quality assessment and life after stroke. Research priorities for translational stroke research were also identified. Documents were prepared by a working group and were open to public comments. The final document was prepared after a workshop in Munich on 21-23 March 2018. Four overarching targets for 2030 were identified: (1) to reduce the absolute number of strokes in Europe by 10%, (2) to treat 90% or more of all patients with stroke in Europe in a dedicated stroke unit as the first level of care, (3) to have national plans for stroke encompassing the entire chain of care, (4) to fully implement national strategies for multisector public health interventions. Overall, 30 targets and 72 research priorities were identified for the seven domains. The ESAP provides a basic road map and sets targets for the implementation of evidence-based preventive actions and stroke services to 2030.

Cardiovascular risk factors in adults with congenital heart defects - Recognised but not treated? An analysis of the German National Register for Congenital Heart Defects

BACKGROUND

As adult congenital heart disease (ACHD) patients are aging, a high prevalence of cardiovascular risk factors is encountered similar to the general population. Currently, data regarding the primary and secondary prevention of acquired cardiovascular disease in ACHD is lacking.

METHODS

The German National Register of Congenital Heart Defects was systematically screened for ACHD patients with established cardiovascular risk factors or documented acquired cardiovascular conditions. Data were analyzed with regard to the according medical treatment.

RESULTS

Overall, 539 patients were included (mean age 38.4 ± 17.7 years, 49.2% female). Diabetes was present in 57 pts. (10.6%), arterial hypertension in 113 pts. (21.0%), hyperlipidaemia in 81 pts. (15.0%) and obesity in 271 pts. (50.2%). 31 pts. (5.8%) were smokers. Coronary artery disease was established in 16 pts. (3.0%), peripheral vascular disease in 9 pts. (1.7%), and cerebrovascular accidents in 141 pts. (26.2%). Out of the patients with coronary artery disease only 81.3% received antithrombotic treatment. Only 18.8% were prescribed a statin. Of the pts. with peripheral arterial disease, 44.4% received an antiplatelet drug, and only 22.2% were on a statin. Patients with arterial hypertension received antihypertensive drugs in 66.4%.

CONCLUSIONS

Primary and secondary prevention of acquired cardiovascular disease in ACHD is underutilized. This highlights the importance of educating primary physicians as well as ACHD physicians about the need of primary and secondary prevention for acquired cardiovascular disease.

Impact of a multifactorial treatment programme on clinical outcomes and cardiovascular risk estimates: a retrospective cohort study from a specialised diabetes centre in Denmark

OBJECTIVES

To investigate the impact of a multifactorial treatment programme in a real-life setting on clinical outcomes and estimated cardiovascular disease (CVD) risk.

DESIGN

A retrospective observational cohort study, using data from the electronic medical records and national registers.

SETTING

Tertiary diabetes centre in Denmark.

PARTICIPANTS

Patients with type 2 diabetes (n=4299) referred to a programme with focus on treatment of hyperglycaemia, hypertension and dyslipidaemia between 1 January 2001 and 1 April 2016.

OUTCOMES

Primary outcomes were changes in haemoglobin A1c (HbA_1c), blood pressure (BP) and low-density lipoprotein (LDL) cholesterol as well as proportion reaching treatment targets. Our secondary outcome was to investigate changes in antidiabetic, antihypertensive and lipid-lowering treatment, together with the impact on estimated CVD risk. Linear mixed model for repeated measurements were used for continuous variables and logistic regression for dichotomous variables.

RESULTS

The patients achieved a mean±SD decrease in HbA_1c, systolic and diastolic BP and LDL cholesterol of 1.0%±0.04% (10.6±0.4 mmol/mol), 6.3±0.4 mm Hg, 2.7±0.2 mm Hg and 0.32±0.02 mmol/L, respectively (p<0.0001). The proportion of patients who met the treatment goal for HbA_1c (<7% (<53 mmol/mol)) increased from 31% to 58% (p<0.0001); for BP (<130/80 mm Hg) from 24% to 34% (p<0.0001), and for LDL cholesterol (<2.5 mmol/L (patients without previous CVD) or <1.8 mmol/L (patients with previous CVD)) from 52% to 65%. Those reaching all three guideline treatment targets increased from 4% to 15% (p<0.0001), and when relaxing the BP target to <140/85 from 8% to 24%. The estimated CVD risk was relatively reduced by 15.2% using the Swedish National Diabetes Register risk engine and 30.9% using the UK Prospective Diabetes Study risk engine.

CONCLUSIONS

Our data support that short-term multifactorial treatment of patients with glycaemic dysregulation in a specialist outpatient setting is both achievable and effective, and associated with a clinically meaningful improvement in CVD risk.

Long-term effects of a Swedish lifestyle intervention programme on lifestyle habits and quality of life in people with increased cardiovascular risk

Aims: The aim of this study was to evaluate the effects of a structured intervention programme on lifestyle habits and quality of life after six months and one year in participants with increased cardiovascular risk. Methods: Participants aged ≥18 years with increased cardiovascular risk were referred from primary health care and hospitals. The programme was launched at an outpatient clinic in a department of cardiology at a university hospital. It consisted of individual visits to a nurse for a health check-up and lifestyle counselling at baseline, after six months and at one year. In addition, five group sessions – focusing on nicotine, alcohol, physical activity, eating habits, stress, sleep and behavioural change – were offered to the participants and their relatives or friends. Lifestyle habits and quality of life were assessed with questionnaires at baseline, after six months and at one year. Results: One hundred participants (64 women, 36 men, age 58±11 years) were included in the programme. Compared with the baseline, significant and favourable changes in reported lifestyle habits were noted. Exercise levels were higher after one year and sedentary time decreased from 7.4 to 6.3 h/day. Dietary habits improved and the number of participants with a high consumption of alcohol decreased. Quality of life improved after one year. Conclusions: Participating in a structured lifestyle programme resulted in improved lifestyle habits and quality of life over one year in people with increased cardiovascular risk. Components such as an inter-professional teamwork, a focus on lifestyle rather than the disease, and combining individual visits and group sessions, might be central to the positive outcome of the programme.

The EUROASPIRE surveys: lessons learned in cardiovascular disease prevention

The Joint European Societies (JES) guidelines on cardiovascular disease (CVD) prevention published in 1994, 1998, 2003, 2007, 2012 and 2016 defined lifestyle and risk factors targets for patients with coronary or other atherosclerotic disease and people at high risk of developing CVD. Guideline implementation in Europe has been evaluated with four cross-sectional EUROASPIRE surveys starting in mid-1990s. The results showed poor lifestyle and risk factor management in patients with CHD and in high CVD risk people with high prevalences of smoking, obesity, central obesity and diabetes. The control of blood pressure, lipids and glucose was far from optimal. A comparison across the recent three surveys provided a unique description of time trends for secondary prevention over a period of 14 years. The results showed adverse lifestyle trends, a substantial increase in obesity, central obesity and diabetes. Despite significant improvement of blood pressure and lipid control many patients were not reaching the risk factor goals and there was no change in glucose control. Comparing the most recent two surveys, there were no major differences in lifestyle and risk factor management in people at high risk of developing CVD. A new approach to CVD prevention integrating primary and secondary prevention into a modern preventive cardiology programme, focusing on lifestyle and risk factor management is required, in order to reduce the risk of CVD events and improve quality of life in patients with CHD and those at high risk of developing CVD.

Lercanidipine in the Management of Hypertension: An Update

Calcium channel blockers (CCBs), particularly dihydropyridine-CCBs, (DHP-CCBs), have an established role in antihypertensive therapy, either as monotherapy or in combination with other antihypertensive drugs. Two hundred and fifty-one papers published in PubMed in English between January 1, 1990, and October 31, 2016, were identified using the keyword "lercanidipine." Lercanidipine is a lipophilic third-generation DHP-CCB, characterized by high vascular selectivity and persistence in the smooth muscle cell membranes. Lercanidipine is devoid of sympathetic activation, and unlike the first and second generation of DHP-CCBs, it dilates both the afferent and the efferent glomerular arteries, while preserving the intraglomerular pressure. In addition, lercanidipine prevents renal damage induced by angiotensin II and demonstrates anti-inflammatory, antioxidant, and anti-atherogenic properties through an increasing bioavailability of endothelial nitric oxide. It is associated with a regression of microvascular structural modifications in hypertensive patients. The efficacy of lercanidipine has been demonstrated in patients with different degrees of hypertension, in the young and elderly and in patients with isolated systolic hypertension. In patients with diabetes and renal impairment, lercanidipine displays a renal protection with a significant decrease of microalbuminuria and improvement of creatinine clearance. Lercanidipine is well tolerated and is associated with a very low rate of adverse events, particularly ankle edema, compared with amlodipine and nifedipine. In conclusion, lercanidipine produces a sustained blood pressure-lowering activity with a high rate of responder/normalized patients, associated with a favorable tolerability profile.

Statin usage, vascular diagnosis and vascular risk factors in Parkinson's disease

Background and aims Vascular disease is a common comorbidity in Parkinson's disease patients. Statins are potentially neuroprotective for Parkinson's disease through non-vascular mechanisms. We investigated prevailing statin use in a Parkinson's disease cohort. Methods and results Data on diagnostic indication for statins, anti-Parkinson therapy, vascular risk factors, and statin prescription, were obtained from electronic medical record review for consecutive Parkinson's disease patients. The ASsessing cardiac risk using Scottish Intercollegiate Guidelines Network system was used to calculate future cardiovascular risk and identify those warranting statin use. Of 441 patients included, 59.9% were male, with a mean age of 68.9 years (standard deviation 10.3). One hundred and seventy-four (39.5%) patients had at least one diagnostic indication for statin use, of whom 136 (78.2%) were prescribed a statin. In the 267 (60.5%) cases without a diagnostic indication, 54 (20.2%) were excluded owing to age limitations defined in ASsessing cardiac risk using Scottish Intercollegiate Guidelines Network. Of the remaining 213, 62 (29.1%) had an ASsessing cardiac risk using Scottish Intercollegiate Guidelines Network score in the recommended range for statin therapy, of whom 15 (24.1%) were prescribed statins. Conclusion There is suboptimal implementation of statin therapy in Parkinson's disease patients. Given the possible neuroprotective effects of statins in Parkinson's disease in addition to reducing cardiovascular risk, reasons for suboptimal implementation warrant further investigation.

Follow-up of Antihypertensive Therapy Improves Blood Pressure Control: Results of HYT (HYperTension survey) Follow-up

INTRODUCTION

Although improved during the past few years, blood pressure control remains sub optimal.

AIM

The impact of follow-up assessment on blood pressure control was evaluated in a group of patients of the HYT (HYperTension survey), treated with a combination of different dihydropyridine calcium-channel blockers (CCBs regimen) and inhibitors of renin-angiotensin-aldosterone system (RAAS) and with uncontrolled blood pressure. This was obtained assessing (a) the rate of blood pressure control at 3 and 6 months of follow-up in the whole group of patients, (b) the rate of blood pressure control and the average blood pressure values in subjects treated with different DHP-CCBs regimen.

METHODS

From the 4993 patients with uncontrolled blood pressure, (BP ≥ 140/90 or ≥140/85 in patients with diabetes), 3729 (mean age 61.2 ± 11.5 years), maintained CCBs regimen combined wih RAAS blockers and were evaluated at 3 and 6 months follow-up. At each visit BP (semiautomatic device, Omron-M6, 3 measurements), heart rate, adverse events and treatment persistence were collected.

RESULTS

At 1st and 2nd follow-up the rate of controlled BP was 63.5 and 72.8% respectively (p < 0.05 vs 35.3% at baseline), whereas in diabetes was 32.5 and 37.9% respectively (p < 0.05 vs 20% at baseline). No differences in heart rate were observed. No differences in control rate were observed between the different CCBs regimen. The incidence of drugs related adverse events was 3.6%.

CONCLUSIONS

These findings provide evidence that: (a) the follow-up of hypertensive patients under therapy increase the rate of blood pressure control; (b) there is no significant difference in the antihypertensive effect between different CCBs regimen;

Mobile phone text messaging to improve medication adherence in secondary prevention of cardiovascular disease

BACKGROUND

Worldwide at least 100 million people are thought to have prevalent cardiovascular disease (CVD). This population has a five times greater chance of suffering a recurrent cardiovascular event than people without known CVD. Secondary CVD prevention is defined as action aimed to reduce the probability of recurrence of such events. Drug interventions have been shown to be cost-effective in reducing this risk and are recommended in international guidelines. However, adherence to recommended treatments remains sub-optimal. In order to influence non-adherence, there is a need to develop scalable and cost-effective behaviour-change interventions.

OBJECTIVES

To assess the effects of mobile phone text messaging in patients with established arterial occlusive events on adherence to treatment, fatal and non-fatal cardiovascular events, and adverse effects.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, the Conference Proceedings Citation Index - Science on Web of Science on 7 November 2016, and two clinical trial registers on 12 November 2016. We contacted authors of included studies for missing information and searched reference lists of relevant papers. We applied no language or date restrictions.

SELECTION CRITERIA

We included randomised trials with at least 50% of the participants with established arterial occlusive events. We included trials investigating interventions using short message service (SMS) or multimedia messaging service (MMS) with the aim to improve adherence to medication for the secondary prevention of cardiovascular events. Eligible comparators were no intervention or other modes of communication.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. In addition, we attempted to contact all authors on how the SMS were developed.

MAIN RESULTS

We included seven trials (reported in 13 reports) with 1310 participants randomised. Follow-up ranged from one month to 12 months. Due to heterogeneity in the methods, population and outcome measures, we were unable to conduct meta-analysis on these studies. All seven studies reported on adherence, but using different methods and scales. Six out of seven trials showed a beneficial effect of mobile phone text messaging for medication adherence. Dale 2015a, reported significantly greater medication adherence score in the intervention group (Mean Difference (MD) 0.58, 95% confidence interval (CI) 0.19 to 0.97; 123 participants randomised) at six months. Khonsari 2015 reported less adherence in the control group (Relative Risk (RR) 4.09, 95% CI 1.82 to 9.18; 62 participants randomised) at eight weeks. Pandey 2014 (34 participants randomised) assessed medication adherence through self-reported logs with 90% adherence in the intervention group compared to 70% in the control group at 12 months. Park 2014a (90 participants randomised) reported a greater increase of the medication adherence score in the control group, but also measured adherence with an event monitoring system for a number of medications with adherence levels ranging from 84.1% adherence to 86.2% in the intervention group and 79.7% to 85.7% in the control group at 30 days. Quilici 2013, reported reduced odds of non-adherence in the intervention group (Odds Ratio (OR) 0.43, 95% CI 0.22 to 0.86, 521 participants randomised) at 30 days. Fang 2016, reported that participants given SMS alone had reduced odds of being non-adherent compared to telephone reminders (OR 0.40 95% CI 0.18 to 0.63; 280 patients randomised). Kamal 2015 reported higher levels of adherence in the intervention arm (adjusted MD 0.54, 95% CI 0.22 to 0.85; 200 participants randomised). Khonsari 2015 was the only study to report fatal cardiovascular events and only reported two events, both in the control arm. No study reported on the other primary outcomes. No study reported repetitive thumb injury or road traffic crashes or other adverse events that were related to the intervention.Four authors replied to our questionnaire on SMS development. No study reported examining causes of non-adherence or provided SMS tailored to individual patient characteristics.The included studies were small, heterogeneous and included participants recruited directly after acute events. All studies were assessed as having high risk of bias across at least one domain. Most of the studies came from high-income countries, with two studies conducted in an upper middle-income country (China, Malaysia), and one study from a lower middle-income country (Pakistan). The quality of the evidence was found to be very low. There was no obvious conflicts of interest from authors, although only two declared their funding.

AUTHORS' CONCLUSIONS

While the results of this systematic review are promising, there is insufficient evidence to draw conclusions on the effectiveness of text message-based interventions for adherence to medications for secondary prevention of CVD. Sufficiently powered, high-quality randomised trials are needed, particularly in low- and middle-income countries.

[Correlation of chronic periodontal disease and cardiovascular disease]

The aim of the study was to assess correlative risk of progression of inflammatory periodontal lesions, the development of a systemic inflammatory reaction and cardiovascular diseases. The study involved 89 patients with chronic periodontal disease (CPD) of varying degrees. High cardiovascular disease risk was revealed in 8.8% of patients with moderate and 13.3% of patients with severe periodontal disease. It is proved that an additional factor contributing to the pathogenic relationship between periodontal inflammatory changes and the development of cardiovascular disease is systemic inflammatory response with increased hrC-reactive protein >3.4 mg/l and interleukin-6 to11.0±3.4 mg/l. Changes of blood lipid spectrum with a reduction in apolipoprotein A1 were associated with progression and development of the CPD. Correlations of somatic and dental pathology requires dentists and cardiologists joint efforts to modify common risk factors.

The CAPITAL study (CArdiovascular Prevention wIth Telecardiology in ApuLia): preliminary results

BACKGROUND

The CArdiovascular Prevention wIth Telecardiology in ApuLia (CAPITAL) study aimed to investigate the prevalence of cardiovascular risk factors, the status of cardiovascular prevention, and the compliance to international scientific societies' guidelines on cardiovascular prevention in a Mediterranean region.

METHODS

The CAPITAL study was based on the assessment of cardiovascular risk and compliance to guidelines on cardiovascular prevention, and on an electrocardiogram screening with remote telemedicine support performed in pharmacies of Apulia (Italy); the study was expected to enroll 10 000 consecutive patients accessing their usual pharmacy.

RESULTS

In the first 1000 patients enrolled, 16% were smokers, 9% diabetic, 26% hypertensive, 43% overweight, and 23% obese; 37% of the patients treated with antihypertensive drugs did not achieve the target levels, regardless of the number of antihypertensive drugs given, and 60% of subjects treated with lipid-lowering drugs did not achieve the target levels.Twenty-two per cent of the patients subjected to the lipid-lowering drugs did not check their cholesterol levels in the past 12 months, and 21% of those taking antihypertensive drugs did not check their blood pressure levels.Left ventricular hypertrophy was detected at electrocardiogram examination in 3.4% of the cases, and in 2.6% of the patients with unknown hypertension: 52% of the hypertensive patients were not checked with an electrocardiogram in the past 12 months, 44% of the diabetic patients, and 44% of subjects treated with lipid-lowering drugs.

CONCLUSIONS

The awareness, therapy, and control of cardiovascular risk factors in a Mediterranean real-world population are unsatisfactory. There is a large scope of an improvement in the control of cardiovascular risk factors. Telemedicine support and pharmacy-based assessment may be helpful in implementing strategies aimed at the improvement of cardiovascular prevention.

Determinants of preferences for lifestyle changes versus medication and beliefs in ability to maintain lifestyle changes. A population-based survey

Preferences for medication treatment versus lifestyle changes are of major importance in the management of chronic diseases. This study aims to investigate determinants of preference for lifestyle changes versus medication for prevention of cardiovascular disease as well as determinants of respondents' beliefs in their ability to maintain lifestyle changes. A representative sample of 40-60-year old Danish inhabitants was in 2012 invited to a survey and were asked to imagine that they had been diagnosed as being at increased risk of heart disease. Subsequently they were presented with a choice between a preventive medical intervention versus lifestyle change. The study population for the present paper comprises 1069 participants. A total of 962 participants preferred lifestyle changes to medication treatment. Significant determinants for preferring lifestyle changes were female gender and high level of physical activity. Significant determinants for not opting for lifestyle changes were being self-employed, poor self-rated health and smoking. Low educational attainment, lifestyle risk factors, self-reported health-related challenges and prior experience with heart disease were associated with a low belief in ability to maintain lifestyle changes. For conclusion we found a pervasive preference for lifestyle changes over medical treatment when individuals were promised the same benefits. Lifestyle risk factors and socioeconomic characteristics were associated with preference for lifestyle changes as well as belief in ability to maintain lifestyle changes. For health professionals risk communication should not only focus on patient preferences but also on patients' beliefs in their own ability to initiate lifestyle changes and possible barriers against maintaining changes.

Epidemiology and prevention of cardiovascular disease: Quo vadis?

With observational epidemiological studies it has been possible in the 1950-60 s to identify what has been called cardiovascular risk factors. The multifactorial origin of atherothrombotic cardiovascular disease has been elucidated and in multifactorial intervention trials it was demonstrated that lifestyle changes related to smoking, diet and exercise can prevent the incidence of premature cardiovascular events. The application of that knowledge at the level of the community has resulted in a reversal of the cardiovascular disease epidemic. More investment is needed in the prevention of the development of cardiovascular risk from childhood onwards. More studies are needed to examine the long-term effects of low-intensity exposure to environmental factors on the cardiovascular system using the most appropriate study design and biosensors. More epidemiological studies are needed to evaluate societal changes on cardiovascular disease. Given the actual knowledge on how to prevent cardiovascular disease there is a need for a shift from aetiological epidemiological research into preventive research.

Under-prescribing of Prevention Drugs and Primary Prevention of Stroke and Transient Ischaemic Attack in UK General Practice: A Retrospective Analysis

BACKGROUND

Stroke is a leading cause of death and disability; worldwide it is estimated that 16.9 million people have a first stroke each year. Lipid-lowering, anticoagulant, and antihypertensive drugs can prevent strokes, but may be underused.

METHODS AND FINDINGS

We analysed anonymised electronic primary care records from a United Kingdom (UK) primary care database that covers approximately 6% of the UK population. Patients with first-ever stroke/transient ischaemic attack (TIA), ≥18 y, with diagnosis between 1 January 2009 and 31 December 2013, were included. Drugs were considered under-prescribed when lipid-lowering, anticoagulant, or antihypertensive drugs were clinically indicated but were not prescribed prior to the time of stroke or TIA. The proportions of strokes or TIAs with prevention drugs under-prescribed, when clinically indicated, were calculated. In all, 29,043 stroke/TIA patients met the inclusion criteria; 17,680 had ≥1 prevention drug clinically indicated: 16,028 had lipid-lowering drugs indicated, 3,194 anticoagulant drugs, and 7,008 antihypertensive drugs. At least one prevention drug was not prescribed when clinically indicated in 54% (9,579/17,680) of stroke/TIA patients: 49% (7,836/16,028) were not prescribed lipid-lowering drugs, 52% (1,647/3,194) were not prescribed anticoagulant drugs, and 25% (1,740/7,008) were not prescribed antihypertensive drugs. The limitations of our study are that our definition of under-prescribing of drugs for stroke/TIA prevention did not address patients' adherence to medication or medication targets, such as blood pressure levels.

CONCLUSIONS

In our study, over half of people eligible for lipid-lowering, anticoagulant, or antihypertensive drugs were not prescribed them prior to first stroke/TIA. We estimate that approximately 12,000 first strokes could potentially be prevented annually in the UK through optimal prescribing of these drugs. Improving prescription of lipid-lowering, anticoagulant, and antihypertensive drugs is important to reduce the incidence and burden of stroke and TIA.

Statins are underused in recent-onset Parkinson's disease with increased vascular risk: findings from the UK Tracking Parkinson's and Oxford Parkinson's Disease Centre (OPDC) discovery cohorts

BACKGROUND

Cardiovascular disease (CVD) influences phenotypic variation in Parkinson's disease (PD), and is usually an indication for statin therapy. It is less clear whether cardiovascular risk factors influence PD phenotype, and if statins are prescribed appropriately.

OBJECTIVES

To quantify vascular risk and statin use in recent-onset PD, and examine the relationship between vascular risk, PD severity and phenotype.

METHODS

Cardiovascular risk was quantified using the QRISK2 calculator (high ≥20%, medium ≥10 and <20%, low risk <10%). Motor severity and phenotype were assessed using the Movement Disorder Society Unified PD Rating Scale (UPDRS) and cognition by the Montreal cognitive assessment.

RESULTS

In 2909 individuals with recent-onset PD, the mean age was 67.5 years (SD 9.3), 63.5% were men and the mean disease duration was 1.3 years (SD 0.9). 33.8% of cases had high vascular risk, 28.7% medium risk, and 22.3% low risk, while 15.2% of cases had established CVD. Increasing vascular risk and CVD were associated with older age (p<0.001), worse motor score (p<0.001), more cognitive impairment (p<0.001) and worse motor phenotype (p=0.021). Statins were prescribed in 37.2% with high vascular risk, 15.1% with medium vascular risk and 6.5% with low vascular risk, which compared with statin usage in 75.3% of those with CVD.

CONCLUSIONS

Over 60% of recent-onset PD patients have high or medium cardiovascular risk (meriting statin usage), which is associated with a worse motor and cognitive phenotype. Statins are underused in these patients, compared with those with vascular disease, which is a missed opportunity for preventive treatment.

TRIAL REGISTRATION NUMBER

GN11NE062, NCT02881099.

Lifestyle and risk factor management in people at high risk of cardiovascular disease. A report from the European Society of Cardiology European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) IV cross-sectional survey in 14 European regions

Background European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) IV in primary care was a cross-sectional survey carried out by the European Society of Cardiology, EURObservational Research Programme in 2014-2015 in 71 centres from 14 European countries. The main objective was to determine whether the 2012 Joint European Societies' guidelines on cardiovascular disease (CVD) prevention in people at high CVD risk have been followed in clinical practice. Methods Patients without a history of atherosclerotic disease started on either blood pressure and/or lipid and/or glucose-lowering treatments were identified and interviewed at least six months after the start of medication. Results Medical notes of 6700 patients were reviewed, and 4579 patients (58.7% women; mean age 58.8 (standard deviation (SD) 11.3) years) interviewed (interview rate 68.3%). Overall, 16.6% were smokers, 39.9% were overweight (body mass index (BMI)≥25 and <30 kg/m²), 43.5% obese (BMI ≥30 kg/m²) and 63.9% centrally obese (waist circumference of ≥88 cm for women, ≥102 cm for men). The medical risk factor control was very poor, with less than half (42.8%) of the patients on blood pressure lowering medication reaching the target of <140/90 mm Hg (<140/80 mm Hg in people with self-reported diabetes). Among treated dyslipidaemic patients only 32.7% attained the low-density lipoprotein (LDL)-cholesterol target of <2.5 mmol/l. Among people treated for type 2 diabetes mellitus, 58.5% achieved the glycated haemoglobin (HbA1c) target of <7.0%. Conclusion The EUROASPIRE IV survey shows that large proportions of patients at high CVD risk have unhealthy lifestyle habits and uncontrolled blood pressure, lipids and diabetes. The present data make it clear that more efforts must be taken to improve cardiovascular prevention in people at high CVD risk.

Dyslipidaemia in the Middle East: Current status and a call for action

The increase in the cardiovascular disease (CVD)-associated mortality rate in the Middle East (ME) is among the highest in the world. The aim of this article is to review the current prevalence of dyslipidaemia and known gaps in its management in the ME region, and to propose initiatives to address the burden of dyslipidaemia. Published literature on the epidemiology of dyslipidaemia in the ME region was presented and discussed at an expert meeting that provided the basis of this review article. The high prevalence of metabolic syndrome, diabetes, familial hypercholesterolaemia (FH) and consanguineous marriages, in the ME region, results in a pattern of dyslipidaemia (low high-density lipoprotein cholesterol and high triglycerides) that is different from many other regions of the world. Early prevention and control of dyslipidaemia is of paramount importance to reduce the risk of developing CVD. Education of the public and healthcare professionals and developing preventive programs, FH registries and regional guidelines on dyslipidaemia are the keys to dyslipidaemia management in the ME region.

Factors influencing low-density lipoprotein cholesterol target achievement in primary care - Results from DYSIS China

BACKGROUND

Primary care facilities are the base for hypercholesterolemia treatment. However, data regarding the effectiveness of lipid management in primary care are lacking.

METHODS AND RESULTS

To evaluate lipid management in the primary care setting in China, we compared patients' characteristics and lipid management outcomes between 6100 outpatients treated at primary care versus 19,217 patients in non-primary settings using data from the DYSlipidemia International Study-China (DYSIS-CHINA). Compared to patients treated at non-primary hospitals, patients who received treatment at primary settings were younger, thinner, and were more likely to be female and to have a family history of premature CVD. Overall, 26.8% of very high-risk and 40.8% of high-risk patients achieved the LDL-C target with primary care treatment, whereas these target rates were 41.2% (p<0.001) and 58.6% (p<0.001), respectively, among patients treated at non-primary hospitals. High-dose statin therapy was underused in primary care patients compared to non-primary hospital patients (p<0.001). Logistic regression analysis showed that female gender, diabetes, and obesity were negative factors, whereas life-style modification and use of high-dose statin (40mg/d simvastatin equivalent) were favorable factors in predicting LDL-C target attainment in the primary care setting.

CONCLUSION

Sedentary life style, alcohol drinking, and use of suboptimal statin dosage are key factors that unfavorably affect the LDL-C target rate among patients treated at primary care facilities in China. Sufficient training for primary care physicians regarding proper statin use and support for the combined use of a statin with ezetimibe could promote LDL-C target attainment in primary care.