The Ghana heart initiative - a health system strengthening approach as index intervention model to solving Ghana's cardiovascular disease burden

Cardiovascular diseases (CVD) are the leading cause of death worldwide, with 80% of these deaths occurring in low-middle income countries (LMICs). In Ghana and across Africa, CVDs have emerged as the leading causes of death primarily due to undetected and under treated hypertension, yet less than 5% of resources allocated to health in these resource-poor countries go into non-communicable diseases (NCD) including CVD prevention and management. Consequently, most countries in Africa do not have contextually appropriate and sustainable health system framework to prevent, detect and manage CVD to achieve Universal Health Coverage (UHC) in CVD care through improved Primary Health Care (PHC) with the aim of achieving Sustainable Development Goals (SDG) in CVD/NCD. In view of this, the Ghana Heart Initiative (GHI) was envisaged as a national strategy to address the identified gaps using a health system and a population-based approach to reduce the national burden of CVDs. The GHI intervention includes the development of guidelines and training manuals; training, equipment support, establishment of a national call/support center, and improvement in the national data capturing system for CVDs and NCD, management of Hypertension, Deep Vein Thrombosis (DVT) and Heart Failure (HF). Following the implementation of the GHI concept, a national CVD Management Guideline was developed and 300-health facilities across the different levels of care including one teaching hospital, was also supported with basic life-saving equipment. In addition, more than 1,500 healthcare workers also reported improvement in their knowledge and skills in the management and treatment of CVD-related cases in their health facilities. These are key contributions to strengthening the health system for CVD care and learning lessons for scale up.

Patients' preferences for secondary prevention following a coronary event

Objective

Despite clear evidence on the effectiveness of secondary prevention, patients with coronary artery disease frequently fail to reach guideline-based risk factor targets. Integrating patients' preferences into treatment decisions has been recommended to reduce this gap. However, this requires knowledge about patient treatment preferences. Therefore, through a survey study, we aimed to explore which risk factors patients self-perceived, prioritised for improvement, and needed support with after a recent hospitalisation for coronary heart disease.

Methods

A digital questionnaire was presented to patients > 18 years recently discharged (≤3 months) from an acute coronary care unit in the Netherlands (Europe). Patients could select from eight cardiovascular risk factors that they (1) self-perceived, (2) prioritised for improvement, and (3) needed support to improve. Patients' perceived risk factors were compared to those documented in the medical records.

Results

Respondents (N = 254, 26 % women), mean age 64 (SD 10) years, identified 'physical inactivity' more frequently than their medical records (140 patients vs. 91 records, p < 0.001), while three other risk factors were reported with equal and four with lower frequency. 'Physical inactivity', 'overweight' and 'stress' were most frequently prioritised for improvement (82 %, 88 % and 78 %) and professional support (64 %, 50 % and 58 %), with 87 % preferring lifestyle optimisation if this would reduce drug use.

Conclusions

Patients with a recent coronary event show significant disparities in identifying risk factors compared to their medical records. They tend to prefer improving lifestyle- over drug-modifiable risk factors, particularly physical inactivity, overweight and stress, and indicate the need for support in improving these factors.

Prevalence of Cardiovascular Disease and Risk Factors in Ghana: A Systematic Review and Meta-analysis

Background

The increasing cardiovascular disease (CVD) burden threatens the global population as the major cause of disability and premature death. Data are scarce on the magnitude of CVD among the population in West Africa, particularly in Ghana. This study examined the available scientific evidence to determine the pooled prevalence (PP) of CVD and risk factors in Ghana.

Methods

We searched electronic databases such as PubMed, Google Scholar, the Cochrane Library, Science Direct and Africa Journal Online databases to identify literature published from the start of the indexing of the database to 10th February 2023. All articles published in the English language that assessed the prevalence of CVD or reported on CVD in Ghana were included. Two authors independently performed the study selection, assessed the risk of bias, extracted the data and checked by the third author. The effect sizes and pooled odds ratio (POR) were determined using the random-effects DerSimonian-Laird (DL) model.

Result

Sixteen studies with 58912 participants from 1954 to 2022 were included in the meta-analysis. Six studies out of 16 reported more than one prevalence of CVD, giving a total of 59 estimates for PP. The PP of CVD in the general population in Ghana was 10.34% (95% Cl: [8.48, 12.20]; l2 99.54%, p < 0.001). Based on the subgroup analysis, the prevalence of CVD was higher in hospital-based settings at 10.74% (95%, confidence interval [Cl]: 8.69, 12.79) than in community-based settings at 5.04% (95% Cl: 2.54, 7.53). The risk factors were male gender (pooled odds ratio [POR]: 1.66; 95% CI: 1.02, 2.70), old age (POR: 1.32; 95% CI: 1.21, 1.45), unemployment (POR: 2.62; 95% CI: 1.33, 5.16), diabetes (POR: 2.79; 95% CI: 1.62, 4.81) and hypertension (POR: 3.41; 95% CI: 1.75, 6.66).

Conclusion

The prevalence of CVD was high in Ghana. Urgent interventions are needed for the prevention and management of the high burden of CVD and its risk factors.

Validation of Systematic Coronary Risk Evaluation 2 (SCORE2) and SCORE2-Older Persons in the EPIC-Norfolk prospective population cohort

AIMS

The European Systematic Coronary Risk Evaluation 2 (SCORE2) and SCORE2-Older Persons (OP) models are recommended to identify individuals at high 10-year risk for cardiovascular disease (CVD). Independent validation and assessment of clinical utility is needed. This study aims to assess discrimination, calibration, and clinical utility of low-risk SCORE2 and SCORE2-OP.

METHODS AND RESULTS

Validation in individuals aged 40-69 years (SCORE2) and 70-79 years (SCORE2-OP) without baseline CVD or diabetes from the European Prospective Investigation of Cancer (EPIC) Norfolk prospective population study. We compared 10-year CVD risk estimates with observed outcomes (cardiovascular mortality, non-fatal myocardial infarction, and stroke). For SCORE2, 19 560 individuals (57% women) had 10-year CVD risk estimates of 3.7% [95% confidence interval (CI) 3.6-3.7] vs. observed 3.8% (95% CI 3.6-4.1) [observed (O)/expected (E) ratio 1.0 (95% CI 1.0-1.1)]. The area under the curve (AUC) was 0.75 (95% CI 0.74-0.77), with underestimation of risk in men [O/E 1.4 (95% CI 1.3-1.6)] and overestimation in women [O/E 0.7 (95% CI 0.6-0.8)]. Decision curve analysis (DCA) showed clinical benefit. Systematic Coronary Risk Evaluation 2-Older Persons in 3113 individuals (58% women) predicted 10-year CVD events in 10.2% (95% CI 10.1-10.3) vs. observed 15.3% (95% CI 14.0-16.5) [O/E ratio 1.6 (95% CI 1.5-1.7)]. The AUC was 0.63 (95% CI 0.60-0.65) with underestimation of risk across sex and risk ranges. Decision curve analysis showed limited clinical benefit.

CONCLUSION

In a UK population cohort, the SCORE2 low-risk model showed fair discrimination and calibration, with clinical benefit for preventive treatment initiation decisions. In contrast, in individuals aged 70-79 years, SCORE2-OP demonstrated poor discrimination, underestimated risk in both sexes, and limited clinical utility.

Impact of implementing Dutch versus European guideline risk factor targets in older patients with ischaemic heart disease

BACKGROUND

In patients with ischaemic heart disease (IHD) aged > 70 years, Dutch and European guidelines recommend different treatment targets: low-density lipoprotein cholesterol (LDL-c) < 2.6 versus < 1.4 mmol/l and systolic blood pressure (SBP) < 140 versus < 130 mm Hg, respectively. How this impacts cardiovascular event-free life expectancy has not been investigated. The study objective was to compare estimated lifelong treatment benefits of implementing Dutch and European LDL‑c and SBP targets.

METHODS

Data from patients aged 71-80 years hospitalised for IHD in 2017-2019 were extracted from the PHARMO Database Network, which links primary and secondary healthcare settings, with follow-up until 31 December 2020. Potential benefit according to treatment strategy (in gain in event-free years) was estimated using the SMART-REACH model.

RESULTS

Of the 3003 eligible patients, 1186 (39%) had missing LDL‑c and/or SBP measurements. Of the 1817 included patients (36% women, median age at event: 74 years (interquartile range (IQR): 72-77), 84% achieved the Dutch targets for both LDL‑c and SBP; for European targets, this was 23% and 61%, respectively. If Dutch targets were met for LDL‑c and SBP (n = 1281), the additional effect of reaching European targets was a median gain of 0.6 event-free life years (IQR: 0.3-1.0). The greatest effect could be reached in patients not reaching Dutch targets (n = 501), with a median gain of 0.6 (IQR: 0.2-1.2) and 1.7 (IQR: 1.2-2.5) event-free years with Dutch versus European targets.

CONCLUSION

In patients aged > 70 years with IHD, implementation of European targets resulted in a greater gain of event-free years compared with Dutch targets, especially in patients with poorer risk factor control. The considerable number of patients with missing risk factor documentation suggested additional opportunities for risk reduction.

Quality of athlete screening for high-risk cardiovascular conditions-A systematic review

BACKGROUND

Sudden cardiac death (SCD) is the leading medical cause of death in athletes. To prevent SCD, screening for high-risk cardiovascular conditions (HRCC) is recommended. Screening strategies are based on a limited number of studies and expert consensus. However, evidence and efficacy of athlete HRCC screening is unclear.

OBJECTIVE

To determine methodological quality and quality of evidence of athlete screening, and screening efficacy to detect HRCC in a systematic review.

METHODS

We performed a systematic search of Medline, Embase, Scopus and Cochrane Library up to June 2021. We included articles containing original data of athlete cardiovascular screening, providing details of screening strategies, test results and HRCC detection. We assessed methodological quality of the included articles by QUADAS-2, quality of evidence of athlete HRCC screening by GRADE, and athlete HRCC screening efficacy by SWiM.

RESULTS

Of 2720 citations, we included 33 articles (1991-2018), comprising 82 417 athletes (26.7% elite, 73.4% competitive, 21.7% women, 75.2% aged ≤35). Methodological quality was 'very low' (33 articles), caused by absence of data blinding and inappropriate statistical analysis. Quality of evidence was 'very low' (33 articles), due to observational designs and population heterogeneity. Screening efficacy could not be reliably established. The prevalence of HRCC was 0.43% with false positive rate (FPR) 13.0%.

CONCLUSIONS

Methodological quality and quality of evidence on athlete screening are suboptimal. Efficacy could not be reliably established. The prevalence of screen detected HRCC was very low and FPR high. Given the limitations of the evidence, individual recommendations need to be prudent.

A multilevel and multicenter assessment of health care system capacity to manage cardiovascular diseases in Africa: a baseline study of the Ghana Heart Initiative

INTRODUCTION

Cardiovascular diseases (CVD) remain the leading cause of death worldwide, with over 70% of these deaths occurring in low- and middle-income regions such as Africa. However, most countries in Africa do not have the capacity to manage CVD. The Ghana Heart Initiative has been an ongoing national program since 2018, aimed at improving CVD care and thus reducing the death rates of these diseases in Ghana. This study therefore aimed at assessing the impact of this initiative by identifying, at baseline, the gaps in the management of CVDs within the health system to develop robust measures to bolster CVD management and care in Ghana.

METHODS

This study employed a cross-sectional study design and was conducted from November 2019 to March 2020 in 44 health facilities in the Greater Accra region. The assessment covered CVD management, equipment availability, knowledge of health workers in CVD and others including the CVD management support system, availability of CVD management guidelines and CVD/NCD indicators in the District Health Information Management System (DHIMS2).

RESULTS

The baseline data showed a total of 85,612 outpatient attendants over the period in the study facilities, 70% were women and 364(0.4%) were newly diagnosed with hypertension. A total of 83% of the newly diagnosed hypertensives were put on treatment, 56.3% (171) continued treatment during the study period and less than 10% (5%) had their blood pressure controlled at the end of the study (in March 2020). Other gaps identified included suboptimal health worker knowledge in CVD management (mean score of 69.0 ± 13.0, p < 0.05), lack of equipment for prompt CVD emergency diagnosis, poor management and monitoring of CVD care across all levels of health care, lack of standardized protocol on CVD management, and limited number of indicators on CVD in the National Database (i.e., DHIMS2) for CVD monitoring.

CONCLUSION

This study shows that there are gaps in CVD care and therefore, there is a need to address such gaps to improve the capacity of the health system to effectively manage CVDs in Ghana.

Unexploited potential of risk factor treatment in patients with atherosclerotic cardiovascular disease

BACKGROUND

Most patients with atherosclerotic cardiovascular disease remain at (very) high risk for recurrent events due to suboptimal risk factor control.

AIM

This study aimed to quantify the potential of maximal risk factor treatment on ten-year and lifetime risk of recurrent atherosclerotic cardiovascular events in patients one year after a coronary event.

METHODS

Pooled data from six studies: RESPONSE 1 and 2, OPTICARE, EUROASPIRE IV and V and HELIUS. Patients aged ≥45 years at ≥6 months after coronary event were included. The SMART-REACH score was used to estimate ten-year and lifetime risk of recurrent atherosclerotic cardiovascular events with current treatment, and potential risk reduction and gains in event-free years with maximal treatment (lifestyle and pharmacological).

RESULTS

In 3,230 atherosclerotic cardiovascular disease patients (24% women), at median (IQR) 1.1 years (1.0-1.8) after index event, ten-year risk was median (IQR) 20% (15%-27%) and lifetime risk 54% (47-63). Whereas 70% used conventional medication, 82% had ≥1 drug-modifiable risk factor not on target. Furthermore, 91% had ≥1 lifestyle-related risk factor not on target. Maximising therapy was associated with a potential reduction of median (IQR) ten-year risk to 6% (4%-8%) and of lifetime risk to 20% (15%-27%), and a median (IQR) gain of 7.3 (5.4-10.4) ASCVD event-free years.

CONCLUSIONS

Among patients with atherosclerotic cardiovascular disease, maximising current, guideline-based preventive therapy has the potential to mitigate a large part of their risk of recurrent events and to add a clinically important number of event-free years to their lifetime.

Cardiovascular mortality risk beyond 10 years in men and women; long-term follow-up from the EPIC-Norfolk prospective population study

Introduction

Current primary prevention strategies in cardiovascular (CV) disease focus on initiating preventive interventions in people at high 10-year risk of CV mortality. However, initiating such strategies should be beneficial not only in the first 10 years, but throughout life. Established risk algorithms estimate the risk of 10-year CV mortality, but limited evidence is available about the relationship between 10-year and longer-term CV mortality.

Purpose

To compare cumulative incidence of CV mortality in a population cohort at 10- and 20-years follow-up, stratified by sex.

Methods

We analysed CV mortality at 10-years and 20-years follow-up using Kaplan-Meier estimates among men and women aged 39–70 years without baseline CV disease or diabetes mellitus in the large, prospective population-based EPIC-Norfolk cohort. CV mortality included death with as underlying or contributing cause ischaemic heart disease, heart failure, cerebrovascular disease or peripheral artery disease.

Results

We analysed data from 20,453 participants (56% women), with a mean age of 56±8 years, and median (IQR) follow-up of 22 (21–23) years. At baseline, there were no clinically relevant differences in CV risk factors between men and women. Overall cumulative CV mortality rate was 1.9% (384 deaths) in the first 10 years, and 7.3% (995 deaths) at 20 years follow-up (ratio 3.8). Among men, 10-year CV mortality was 2.9% (249 deaths), and 9.6% (785 deaths) at 20 years follow-up (ratio 3.3). Among women, CV mortality was 1.2% (135 deaths) at 10 year and 5.5% (594 deaths) at 20 years follow-up (ratio 4.6).

Conclusion

We observed an incremental increase in CV mortality beyond the 10-year scope of current established CV risk algorithms. At 20 years follow-up, CV mortality rates were 3–5 times higher compared with the first decade, indicating that 20-year CV mortality risk for both men and women cannot simply be estimated based on extrapolation of 10-year risk.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): EPIC-Norfolk is supported by programme grants from the Medical Research Council UK (MRC G0401527, MRC G0701863, MRC G1000143) and Cancer Research UK (CRUK 8257).

Let’s get active: patients with a recent coronary event are highly motivated to lose weight and increase physical activity levels

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): NWO-grant

Title (Dutch): Het centraal stellen van behandelvoorkeuren van de individuele patiënt met een chronische hartziekte.

Subtitle: Persoonsgerichte zorg voor hartpatiënten

Introduction

Motivated patients are more likely to successfully improve unhealthy lifestyles. How patients perceive their risk factors and their willingness to improve is an integral part of this motivation. However, such preferences, and how they align with clinicians’ risk perception are seldom systematically assessed in patients with coronary artery disease (CAD).

Purpose

We aimed to investigate preferences in risk factor treatment in patients with CAD, and to compare this with clinicians’ perception of patients’ risks.

Methods

We administered a 10-item questionnaire on patients’ preferences on risk factor treatment in secondary prevention which was developed in consultation with end-users. We sent the questionnaire to approximately 450 patients who were referred to cardiac rehabilitation after recent (&lt;3 months) admission to an acute coronary unit between Feb 2020 and Apr 2021. We demonstrate the results of 6 questions that covered the following subjects relevant to secondary prevention: Q1: risk factor perception, Q2: priority setting, Q3: wanting help, Q4: willingness to change, Q5: motivation to change, Q6: confidence to successfully change. We compared patients risk factor perception with clinicians’ report in the medical record.

Results

A total of 296 patients completed the survey (66% of eligible respondents) at mean (SD) age 64 (10) years on median (IQR) 38 (25-53) days after discharge. Physical activity was much more frequently reported as risk factor by patients (P 55%) compared to clinicians (C 31%), followed by other disparities such as for high cholesterol (P 48% vs. C 36%) and overweight (P 46% vs. C 59%) (Figure 1). Patients were asked which of their perceived risk factors on Q1 was most important to improve (Q2) and for which they wanted help (Q3). Top-3 risk factors chosen for improvement were overweight (87%), physical inactivity (81%), and stress (79%), for which 75% required help with any risk factor, again most frequently with increasing physical activity (64%), overweight (59%) and stress (51%) (Figure 2). Motivation and confidence for improvement of risk factors were high: 87% were willing to adapt their lifestyles, with motivation rates of median (IQR) 8 (7-9) out of 10, and estimated chance for successful improvement of median (IQR) 7 (6-8) out of 10.

Conclusion(s)

Patients who recently suffered from coronary event are highly motivated to lose weight and increase physical inactivity. The use of these patient preferences by the clinician will enable compliance and outcomes with respect to weight loss and improved physical activity.

Overall benefits of smoking cessation in patients with ASCVD are underestimated

Funding Acknowledgements

Type of funding sources: None.

Introduction

New risk prediction models estimate and employ individual ‘treatment benefit’, which can be used to motivate patients with atherosclerotic cardiovascular disease (ASCVD) to quit smoking and to adhere to beneficial pharmacological interventions. However, this treatment benefit is usually calculated for a limited set of cardiovascular outcomes, i.e. years gained without myocardial infarction or stroke, while ignoring non-cardiovascular health benefits and pharmacological side- and adverse effects. Importantly, treatment effect size of medication is smaller in persistent smokers compared to non-smokers, because of the higher overall mortality of the smokers. By disregarding non-cardiovascular outcomes, the overall benefit of smoking cessation will be underestimated.

Purpose

We estimated and compared the treatment benefits – expressed as ‘gain in years without major cardiovascular events’ – of smoking cessation versus persistent smoking with targeted pharmaceutical interventions in patients with established ASCVD treated with anti-platelet agents, statins and anti-hypertensive drugs.

Methods

We pooled individual-level risk factors data from six large, recent prospective studies: RESPONSE 1 and 2, OPTICARE, EUROASPIRE IV and V and HELIUS. We included patients aged ≥45 years who persisted in smoking ≥6 months after acute coronary syndrome or revascularisation. The primary outcome was SMART-REACH estimated treatment benefit expressed as gain in years without a myocardial infarction or stroke. We compared the cardiovascular treatment benefit of smoking cessation versus the use of one or more pharmaceutical treatments: bempedoic acid, colchicine and PCSK9 inhibitors.

Results

We included 989 smokers with established ASCVD (23% female), with mean age of 60 (SD 8) years at median 1.2 (IQR 1.0-2.0) years post-index event. A mean of 4.81 (95%CI 4.73-4.89) event-free years would be gained through smoking cessation. Persistent smoking with maximal pharmaceutical treatment resulted in a comparable gain of 4.83 (95% CI 4.72-4.93) event-free years.(Figure)

Conclusion

The estimated lifetime treatment benefit of smoking cessation appeared to be comparable to the use of several pharmaceutical treatments combined, even when the analysis was limited to major cardiovascular events. This substantial health benefit underscores smoking cessation to be one of the most important actions to improve the overall health of patients with established ASCVD. To accurately compare treatment options, overall benefits and harms should be considered, in addition to the patients’ preferences, in a shared decision making process.

Lifetime versus 10-year risk of recurrent events in patients with cardiovascular disease: impact of age

Funding Acknowledgements

Type of funding sources: None.

Introduction

Most risk models for patients with established atherosclerotic cardiovascular disease (ASCVD) calculate short-term risk of recurrent events and death, typically for a duration of 10 years. However, lifetime risk estimates may better support the healthcare professional in selecting patients for intensified preventive treatment (1). Also, a cross-sectional study suggested that communicating lifetime risk to ASCVD patients enhances risk perception and willingness for therapy (2). In the new ESC prevention guideline, however, 10-year risk estimates remain standard for ASCVD patients but the additional use of lifetime risk is recommended for communication in the shared decision-making process (3).

Purpose

We therefore aimed to compare estimates of 10-year with lifetime risk of recurrent ASCVD events or death, stratified by age.

Methods

We pooled individual-level data on risk factors from six large, recent prospective studies (RESPONSE 1 and 2, OPTICARE, EUROASPIRE IV and V and HELIUS). We included Dutch patients aged ≥45 years with a follow-up of ≥6 months after acute coronary syndrome or revascularisation. The SMART-REACH models were used to estimate the difference between 10-year and lifetime risk of recurrent myocardial infarction, stroke, or cardiovascular death, stratified by age (&lt;55, 55-65, 65-75, ≥75 years).

Results

In 3,230 ASCVD patients (24% women), mean age 61±8 years, at median follow-up 1.1 (IQR 1.0-1.8) years after index event, SMART-REACH 10-year risk was 23±11% versus lifetime 56±11%. (Figure 1) We found a considerable difference between 10-year and lifetime risk in patients aged 45-55 years (18±8% vs. 61±10%). Discrepancies decreased with increasing age, with similar estimates in the highest (75-85) age group. (Figure 2).

Conclusion

Lifetime risk of a limited set of cardiovascular outcomes rather than 10-year risk may provide a more complete estimate of future ASCVD disease burden, as especially in younger patients 10-year risk is usually low, even in the presence of risk factors.

Sarcopenia and its relation to protein intake across older ethnic populations in the Netherlands: the HELIUS study

Objective: To examine the prevalence of sarcopenia and its association with protein intake in men and women in a multi-ethnic population.Design: We used cross-sectional data from the HELIUS (Healthy Life in an Urban Setting) study, which includes nearly 25,000 participants (aged 18-70 years) of Dutch, South-Asian Surinamese, African Surinamese, Turkish, Moroccan, and Ghanaian ethnic origin. For the current study, we included 5161 individuals aged 55 years and older. Sarcopenia was defined according to the EWGSOP2. In a subsample (N = 1371), protein intake was measured using ethnic-specific Food Frequency Questionnaires. Descriptive analyses were performed to study sarcopenia prevalence across ethnic groups in men and women, and logistic regression analyses were used to study associations between protein intake and sarcopenia.Results: Sarcopenia prevalence was found to be sex- and ethnic-specific, varying from 29.8% in Turkish to 61.3% in South-Asian Surinamese men and ranging from 2.4% in Turkish up to 30.5% in South-Asian Surinamese women. Higher protein intake was associated with a 4% lower odds of sarcopenia in the subsample (OR = 0.96, 95%-CI: 0.92-0.99) and across ethnic groups, being only significant in the South-Asian Surinamese group.Conclusion: Ethnic differences in the prevalence of sarcopenia and its association with protein intake suggest the need to target specific ethnic groups for prevention or treatment of sarcopenia.

The Cardiac Care Bridge transitional care program for the management of older high-risk cardiac patients: An economic evaluation alongside a randomized controlled trial

Objective

To evaluate the cost-effectiveness of the Cardiac Care Bridge (CCB) nurse-led transitional care program in older (≥70 years) cardiac patients compared to usual care.

Methods

The intervention group (n = 153) received the CCB program consisting of case management, disease management and home-based cardiac rehabilitation in the transition from hospital to home on top of usual care and was compared with the usual care group (n = 153). Outcomes included a composite measure of first all-cause unplanned hospital readmission or mortality, Quality Adjusted Life Years (QALYs) and societal costs within six months follow-up. Missing data were imputed using multiple imputation. Statistical uncertainty surrounding Incremental Cost-Effectiveness Ratios (ICERs) was estimated by using bootstrapped seemingly unrelated regression.

Results

No significant between group differences in the composite outcome of readmission or mortality nor in societal costs were observed. QALYs were statistically significantly lower in the intervention group, mean difference -0.03 (95% CI: -0.07; -0.02). Cost-effectiveness acceptability curves showed that the maximum probability of the intervention being cost-effective was 0.31 at a Willingness To Pay (WTP) of €0,00 and 0.14 at a WTP of €50,000 per composite outcome prevented and 0.32 and 0.21, respectively per QALY gained.

Conclusion

The CCB program was on average more expensive and less effective compared to usual care, indicating that the CCB program is dominated by usual care. Therefore, the CCB program cannot be considered cost-effective compared to usual care.

The challenge of choosing in cardiovascular risk management

Cardiovascular disease (CVD) is a major cause of morbidity and mortality worldwide. For many years guidelines have listed optimal preventive therapy. More recently, novel therapeutic options have broadened the options for state-of-the-art CV risk management (CVRM). In the majority of patients with CVD, risk lowering can be achieved by utilising standard preventive medication combined with lifestyle modifications. In a minority of patients, add-on therapies should be considered to further reduce the large residual CV risk. However, the choice of which drug combination to prescribe and in which patients has become increasingly complicated, and is dependent on both the absolute CV risk and the reason for the high risk. In this review, we discuss therapeutic decisions in CVRM, focusing on (1) the absolute CV risk of the patient and (2) the pros and cons of novel treatment options.

Impact of a Patient's Baseline Risk on the Relative Benefit and Harm of a Preventive Treatment Strategy: Applying Trial Results in Clinical Decision Making

Background

For translating an overall trial result into an individual patient’s expected absolute treatment effect, differences in relative treatment effect between patients need to be taken into account. The aim of this study was to evaluate whether relative treatment effects of medication in 2 large contemporary trials are influenced by multivariable baseline risk of an individual patient.

Methods and Results

In 9361 patients from SPRINT (Systolic Blood Pressure Intervention Trial), risk of major adverse cardiovascular events was assessed using a newly derived risk model. In 18 133 patients from the RE‐LY (Randomized Evaluation of Long‐Term Anticoagulant Therapy) trial, risk of stroke or systemic embolism and major bleeding was assessed using the Global Anticoagulant Registry in the Field–Atrial Fibrillation risk model. Heterogeneity of trial treatment effect was assessed using Cox models of trial allocation, model linear predictor, and their interaction. There was no significant interaction between baseline risk and relative treatment effect from intensive blood pressure lowering in SPRINT (P=0.92) or from dabigatran compared with warfarin for stroke or systemic embolism in the RE‐LY trial (P=0.71). There was significant interaction between baseline risk and treatment effect from dabigatran versus warfarin in the RE‐LY trial (P<0.001) for major bleeding. Quartile‐specific hazard ratios for bleeding ranged from 0.40 (95% CI, 0.26–0.61) to 1.04 (95% CI, 0.83–1.03) for dabigatran, 110 mg, and from 0.61 (95% CI, 0.42–0.88) to 1.20 (95% CI, 0.97–1.50) for dabigatran, 150 mg, compared with warfarin.

Conclusions

Effect modification of relative treatment effect by individual baseline event risk should be assessed systematically in randomized clinical trials using multivariate risk prediction, not only in terms of treatment efficacy but also for important treatment harms, as a prespecified analysis.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01206062.

The nurse-coordinated cardiac care bridge transitional care programme: a randomised clinical trial

Background

after hospitalisation for cardiac disease, older patients are at high risk of readmission and death.

Objective

the cardiac care bridge (CCB) transitional care programme evaluated the impact of combining case management, disease management and home-based cardiac rehabilitation (CR) on hospital readmission and mortality.

Design

single-blind, randomised clinical trial.

Setting

the trial was conducted in six hospitals in the Netherlands between June 2017 and March 2020. Community-based nurses and physical therapists continued care post-discharge.

Subjects

cardiac patients ≥ 70 years were eligible if they were at high risk of functional loss or if they had had an unplanned hospital admission in the previous 6 months.

Methods

the intervention group received a comprehensive geriatric assessment-based integrated care plan, a face-to-face handover with the community nurse before discharge and follow-up home visits. The community nurse collaborated with a pharmacist and participants received home-based CR from a physical therapist. The primary composite outcome was first all-cause unplanned readmission or mortality at 6 months.

Results

in total, 306 participants were included. Mean age was 82.4 (standard deviation 6.3), 58% had heart failure and 92% were acutely hospitalised. 67% of the intervention key-elements were delivered. The composite outcome incidence was 54.2% (83/153) in the intervention group and 47.7% (73/153) in the control group (risk differences 6.5% [95% confidence intervals, CI −4.7 to 18%], risk ratios 1.14 [95% CI 0.91–1.42], P = 0.253). The study was discontinued prematurely due to implementation activities in usual care.

Conclusion

in high-risk older cardiac patients, the CCB programme did not reduce hospital readmission or mortality within 6 months.

Trial registration

Netherlands Trial Register 6,316, https://www.trialregister.nl/trial/6169

Modifiable lifetime risk for recurrent major cardiovascular events: observations in a contemporary pooled cohort

Introduction

The major modifiable risk factors for atherosclerosis – lifestyle, hypertension, diabetes and cholesterol – collectively account for 80 to 90% of disease burden. Currently, the majority of coronary patients does not meet the guideline-directed treatment targets for these risk factors, resulting in high levels of residual risk. An increasing number of novel preventive drugs aims to reduce this residual risk, but are not considered cost-effective when added routinely to all patients. Quantifying the potential lifetime risk reduction one year after an acute coronary syndrome (ACS) may aid in optimum use of available treatment and value-based use of novel drugs.

Purpose

The purpose of this analysis was to quantify the loss of lifetime risk reduction due to suboptimal modifiable risk factor control in patients with prior ACS or revascularisation.

Methods

We pooled six recent prospective studies (Response 1 [1] and 2 [2], Opticare [3], EuroAspire IV [4] and V [5] and HELIUS [6]) with Dutch patients (n=3,230, 24% women) at mean age 61±8 years and follow-up at median 1.1 [IQR 1.0–1.8] years after an ACS or revascularisation. We investigated individual lifestyle- and drug-modifiable risk factors at guideline-directed targets. Using the SMART-REACH model [7], we calculated % reduction of individual residual lifetime risk for myocardial infarction, stroke, or cardiovascular death and event free years gained by the change from current treatment to a (simulated) guideline-directed optimal situation.

Results

Risk factor control was far from optimal: only 7% met all lifestyle-related risk targets, whereas 10% met none: 30% persist smoking, 79% was overweight (BMI ≥25 kg/m2), of which 40% obese (BMI ≥30 kg/m2), and 45% reported insufficient physical activity (&lt;150 minutes per week). Systolic blood pressure ≥140 mmHg was found in 40%, and LDL-cholesterol ≥1.8 mmol/L or ≥2.5 mmol/L (depending on the target at that time) in 65%. Basic preventive medication use was, however, common: 87% used antithrombotic agents, 85% lipid lowering drugs and 86% any blood pressure lowering drugs. By the change from current to optimal guideline-directed treatment, residual lifetime risk for cardiovascular events and cardiovascular death would decrease from a mean of 54±11% to 25±10% (Figure 1), and a median of 7.4 [IQR 5.2–10.6] event free years would be gained (Figure 2).

Conclusion

Suboptimal risk factor control resulted in avoidable high residual lifetime risk of myocardial infarction, stroke, or cardiovascular death and loss of event free years in patients with prior ACS or revascularisation. This finding highlights the unexploited potential of optimised use of available lifestyle- and drug treatment to significantly reduce residual lifetime risk.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Modifiable residual lifetime riskFigure 2. Lifetime benefit in CVD event free years

An appeal to our government for nationwide policies in the prevention of cardiovascular disease

The high prevalence and burden of cardiovascular diseases (CVD) is largely attributable to unhealthy lifestyle factors such as smoking, alcohol consumption, physical inactivity and unhealthy food habits. Prevention of CVD, through the promotion of healthy lifestyles, appears to be a Sisyphean task for healthcare professionals, as the root causes of an unhealthy lifestyle lie largely outside their scope. Since most lifestyle choices are habitual and a response to environmental cues, rather than rational and deliberate choices, nationwide policies targeting the context in which lifestyle behaviours occur may be highly effective in the prevention of CVD. In this point-of-view article, we emphasise the need for government policies beyond those mentioned in the National Prevention Agreement in the Netherlands to effectively reduce the CVD risk, and we address the commonly raised concerns regarding ‘paternalism’.

Understanding transnational healthcare use in immigrant communities from a cultural systems perspective: a qualitative study of Dutch residents with a Turkish background

OBJECTIVES

Transnational utilisation of healthcare by people with an immigrant background carries risks, including medicalisation and adverse iatrogenic outcomes. We investigated the drivers behind such transnational healthcare use from a cultural perspective on health systems.

DESIGN

Qualitative interview study (2018).

SETTING

Two primary care practices in Amsterdam, the Netherlands.

PARTICIPANTS

Thirteen Dutch patients of Turkish background, who had obtained healthcare in Turkey, and who in general visited the primary care practice more than once a month.

RESULTS

In the respondents' stories, we observed how: (1) cross-border healthcare use was encouraged by cultural mismatches between expected and provided services and by differing explanatory models of illness upheld by patients and Dutch providers; (2) both transnationalism in patients and entitlements to insurance reimbursement facilitated the use of Turkish health services to bypass perceived barriers in the Dutch system; (3) cultural mismatches were reinforced during general practitioner consultations after the patients' return to the Netherlands, thereby inducing further service use abroad.

CONCLUSIONS

Although cultural system influences are difficult to bridge, measures to reduce the unwelcome consequences of transnational healthcare use may include (1) strengthening the provision of culturally sensitive care in the country of residence and (2) restricting the reimbursement of care in the country of origin while maintaining the option to obtain care abroad.

Effects of a transitional care programme on medication adherence in an older cardiac population: A randomized clinical trial

AIMS

Medication non-adherence post-discharge is common among patients, especially those suffering from chronic medical conditions, and contributes to hospital admissions and mortality. This study aimed to evaluate the effect of the Cardiac Care Bridge (CCB) intervention on medication adherence post-discharge.

METHODS

We performed a secondary analysis of the CCB randomized single-blind trial, a study in patients ≥70 years, at high risk of functional loss and admitted to cardiology departments in six hospitals. In this multi-component intervention study, community nurses performed medication reconciliation and observed medication-related problems (MRPs) during post-discharge home visits, and pharmacists provided recommendations to resolve MRPs. Adherence to high-risk medications was measured using the proportion of days covered (PDC), using pharmacy refill data. Furthermore, MRPs were assessed in the intervention group.

RESULTS

For 198 (64.7%) of 306 CCB patients, data were available on adherence (mean age: 82 years; 58.9% of patients used a multidose drug dispensing [MDD] system). The mean PDC before admission was 92.3% in the intervention group (n = 99) and 88.5% in the control group (n = 99), decreasing to 85.2% and 84.1% post-discharge, respectively (unadjusted difference: -2.6% (95% CI -9.8 to 4.6, P = .473); adjusted difference -3.3 (95% CI -10.3 to 3.7, P = .353)). Post-hoc analysis indicated that a modest beneficial intervention effect may be restricted to MDD non-users (P_interaction  = .085). In total, 77.0% of the patients had at least one MRP post-discharge.

CONCLUSIONS

Our findings indicate that a multi-component intervention, including several components targeting medication adherence in older cardiac patients discharged from hospital back home, did not benefit their medication adherence levels. A modest positive effect on adherence may potentially exist in those patients not using an MDD system. This finding needs replication.

Experiences of frail older cardiac patients with a nurse-coordinated transitional care intervention - a qualitative study

BACKGROUND

Older cardiac patients are at high risk of readmission and mortality. Transitional care interventions (TCIs) might contribute to the prevention of adverse outcomes. The Cardiac Care Bridge program was a randomized nurse-coordinated TCI combining case management, disease management and home-based rehabilitation for hospitalized frail older cardiac patients. This qualitative study explored the experiences of patients' participating in this study, as part of a larger process evaluation as this might support interpretation of the neutral study outcomes. In addition, understanding these experiences could contribute to the design and application of future transitional care interventions for frail older cardiac patients.

METHODS

A generic qualitative approach was used. Semi-structured interviews were performed with 16 patients ≥70 years who participated in the intervention group. Participants were selected by gender, diagnosis, living arrangement and hospital of inclusion. Data were analysed using thematic analysis. In addition, quantitative data about intervention delivery were analysed.

RESULTS

Three themes emerged from the data: 1) appreciation of care continuity; 2) varying experiences with recovery and, 3) the influence of an existing care network. Participants felt supported by the transitional care intervention as they experienced post-discharge support and continuity of care. The perceived contribution of the program in participants' recovery varied. Some participants reported physical improvements while others felt impeded by comorbidities or frailty. The home visits by the community nurse were appreciated, although some participants did not recognize the added value. Participants with an existing healthcare provider network preferred to consult these providers instead of the providers who were involved in the transitional care intervention.

CONCLUSION

Our results contribute to an explanation of the neutral study of a nurse-coordinated transitional care intervention. For future purpose, it is important to identify which patients might benefit most from TCIs. Furthermore, the intensity and content of TCIs could be more personalized by tailoring interventions to older cardiac patients' needs, considering their frailty, self-management skills and existing formal and informal caregiver networks.

Immediate Bystander Cardiopulmonary Resuscitation to Sudden Cardiac Arrest During Sports is Associated with Improved Survival-a Video Analysis

Background

Sudden cardiac arrest (SCA) during sports can be the first symptom of yet undetected cardiovascular conditions. Immediate chest compressions and early defibrillation offer SCA victims the best chance of survival, which requires prompt bystander cardiopulmonary resuscitation (CPR).

Aims

To determine the effect of rapid bystander CPR to SCA during sports by searching for and analyzing videos of these SCA/SCD events from the internet.

Methods

We searched images.google.com, video.google.com, and YouTube.com, and included any camera-witnessed non-traumatic SCA during sports. The rapidity of starting bystander chest compressions and defibrillation was classified as < 3, 3–5, or > 5 min.

Results

We identified and included 29 victims of average age 27.6 ± 8.5 years. Twenty-eight were males, 23 performed at an elite level, and 18 participated in soccer. Bystander CPR < 3 min (7/29) or 3–5 min (1/29) and defibrillation < 3 min was associated with 100% survival. Not performing chest compressions and defibrillation was associated with death (14/29), and > 5 min delay of intervention with worse outcome (death 4/29, severe neurologic dysfunction 1/29).

Conclusions

Analysis of internet videos showed that immediate bystander CPR to non-traumatic SCA during sports was associated with improved survival. This suggests that immediate chest compressions and early defibrillation are crucially important in SCA during sport, as they are in other settings. Optimal use of both will most likely result in survival. Most videos showing recent events did not show an improvement in the proportion of athletes who received early resuscitation, suggesting that the problem of cardiac arrest during sports activity is poorly recognized.

The contribution of obesity to the population burden of high metabolic cardiovascular risk among different ethnic groups. The HELIUS study

BACKGROUND

The burden of cardiovascular risk is distributed unequally between ethnic groups. It is uncertain to what extent this is attributable to ethnic differences in general and abdominal obesity. Therefore, we studied the contribution of general and abdominal obesity to metabolic cardiovascular risk among different ethnic groups.

METHODS

We used data of 21 411 participants of Dutch, South-Asian Surinamese, African-Surinamese, Ghanaian, Turkish or Moroccan origin in Healthy Life in an Urban Setting (Amsterdam, the Netherlands). Obesity was defined using body-mass-index (general) or waist-to-height-ratio (abdominal). High metabolic risk was defined as having at least two of the following: triglycerides ≥1.7 mmol/l, fasting glucose ≥5.6 mmol/l, blood pressure ≥130 mmHg systolic and/or ≥85 mmHg diastolic and high-density lipoprotein cholesterol <1.03 mmol/l (men) or <1.29 mmol/l (women).

RESULTS

Among ethnic minority men, age-adjusted prevalence rates of high metabolic risk ranged from 32 to 59% vs. 33% among Dutch men. Contributions of general obesity to high metabolic risk ranged from 7.1 to 17.8%, vs. 10.1% among Dutch men, whereas contributions of abdominal obesity ranged from 52.1 to 92.3%, vs. 53.9% among Dutch men. Among ethnic minority women, age-adjusted prevalence rates of high metabolic risk ranged from 24 to 35% vs. 12% among Dutch women. Contributions of general obesity ranged from 14.6 to 41.8%, vs. 20% among Dutch women, whereas contributions of abdominal obesity ranged from 68.0 to 92.8%, vs. 72.1% among Dutch women.

CONCLUSIONS

Obesity, especially abdominal obesity, contributes significantly to the prevalence of high metabolic cardiovascular risk. Results suggest that this contribution varies substantially between ethnic groups, which helps explain ethnic differences in cardiovascular risk.

The course of readmission in frail older cardiac patients

AIM

The aim of this study is to explore patients' and (in)formal caregivers' perspectives on their role(s) and contributing factors in the course of unplanned hospital readmission of older cardiac patients in the Cardiac Care Bridge (CCB) program.

DESIGN

This study is a qualitative multiple case study alongside the CCB randomized trial, based on grounded theory principles.

METHODS

Five cases within the intervention group, with an unplanned hospital readmission within six months after randomization, were selected. In each case, semi-structured interviews were held with patients (n = 4), informal caregivers (n = 5), physical therapists (n = 4), and community nurses (n = 5) between April and June 2019. Patients' medical records were collected to reconstruct care processes before the readmission. Thematic analysis and the six-step analysis of Strauss & Corbin have been used.

RESULTS

Three main themes emerged. Patients experienced acute episodes of physical deterioration before unplanned hospital readmission. The involvement of (in)formal caregivers in adequate observation of patients' health status is vital to prevent rehospitalization (theme 1). Patients and (in)formal caregivers' perception of care needs did not always match, which resulted in hampering care support (theme 2). CCB caregivers experienced difficulties in providing care in some cases, resulting in limited care provision in addition to the existing care services (theme 3).

CONCLUSION

Early detection of deteriorating health status that leads to readmission was often lacking, due to the acuteness of the deterioration. Empowerment of patients and their informal caregivers in the recognition of early signs of deterioration and adequate collaboration between caregivers could support early detection. Patients' care needs and expectations should be prioritized to stimulate participation.

IMPACT

(In)formal caregivers may be able to prevent unplanned hospital readmission of older cardiac patients by ensuring: (1) early detection of health deterioration, (2) empowerment of patient and informal caregivers, and (3) clear understanding of patients' care needs and expectations.

Antihypertensives and Statin Therapy for Primary Stroke Prevention: A Secondary Analysis of the HOPE-3 Trial

[Figure: see text].

The performance of the Dutch Safety Management System frailty tool to predict the risk of readmission or mortality in older hospitalised cardiac patients

Background

Early identification of older cardiac patients at high risk of readmission or mortality facilitates targeted deployment of preventive interventions. In the Netherlands, the frailty tool of the Dutch Safety Management System (DSMS-tool) consists of (the risk of) delirium, falling, functional impairment, and malnutrition and is currently used in all older hospitalised patients. However, its predictive performance in older cardiac patients is unknown.

Aim

To estimate the performance of the DSMS-tool alone and combined with other predictors in predicting hospital readmission or mortality within 6 months in acutely hospitalised older cardiac patients.

Methods

An individual patient data meta-analysis was performed on 529 acutely hospitalised cardiac patients ≥70 years from four prospective cohorts. Missing values for predictor and outcome variables were multiply imputed. We explored discrimination and calibration of: (1) the DSMS-tool alone; (2) the four components of the DSMS-tool and adding easily obtainable clinical predictors; (3) the four components of the DSMS-tool and more difficult to obtain predictors. Predictors in model 2 and 3 were selected using backward selection using a threshold of p = 0.157. We used shrunk c-statistics, calibration plots, regression slopes and Hosmer-Lemeshow p-values (P_HL) to describe predictive performance in terms of discrimination and calibration.

Results

The population mean age was 82 years, 52% were males and 51% were admitted for heart failure. DSMS-tool was positive in 45% for delirium, 41% for falling, 37% for functional impairments and 29% for malnutrition. The incidence of hospital readmission or mortality gradually increased from 37 to 60% with increasing DSMS scores. Overall, the DSMS-tool discriminated limited (c-statistic 0.61, 95% 0.56–0.66). The final model included the DSMS-tool, diagnosis at admission and Charlson Comorbidity Index and had a c-statistic of 0.69 (95% 0.63–0.73; P_HL was 0.658).

Discussion

The DSMS-tool alone has limited capacity to accurately estimate the risk of readmission or mortality in hospitalised older cardiac patients. Adding disease-specific risk factor information to the DSMS-tool resulted in a moderately performing model. To optimise the early identification of older hospitalised cardiac patients at high risk, the combination of geriatric and disease-specific predictors should be further explored.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02243-5.

Older patients' perspectives toward lifestyle-related secondary cardiovascular prevention after a hospital admission-a qualitative study

BACKGROUND

lifestyle-related secondary prevention reduces cardiac events and is recommended irrespective of age. However, motivation may be influenced by age and disease progression.

OBJECTIVE

to explore older cardiac patients' perspectives toward lifestyle-related secondary prevention after a hospital admission.

METHODS

a generic qualitative design was used. Semi-structured interviews were performed with cardiac patients ≥ 70 years within 3 months after a hospital admission. The interview guide was based on the Attitudes, Social influence and self-Efficacy (ASE) model. All interviews were analysed using thematic analysis.

RESULTS

eight themes emerged which were linked to the determinants of the ASE-model. The three themes (i) Perspectives are determined by general health and habits, (ii) feeling the threat as a motivator and (iii) balancing between health benefits and quality of life (QoL), were linked to attitude. Regarding social influence, the themes (iv) feeling both encouraged and hindered by family members, and (v) the healthcare professional says so, were identified. For the self-efficacy determinant, (vi) experiences from previous lifestyle changes, (vii) integrating advice in daily life and (viii) feeling limited by functional impairments, emerged as themes.

CONCLUSION

most older cardiac patients made no lifestyle modifications after the last hospital admission and balanced possible benefits against their QoL. Functional impairments frequently limit implementation, in particular of physical activity. Patients' preferences and patient-centred outcomes focusing on QoL and functional independence may be the starting point when healthcare professionals discuss lifestyle modification in older patients. The involvement of family members may help patients to integrate lifestyle-related secondary prevention in daily life.

The influence of partners on successful lifestyle modification in patients with coronary artery disease

BACKGROUND

Marital status is associated with prognosis in patients with cardiovascular disease (CVD). However, the influence of partners on successful modification of lifestyle-related risk factors (LRFs) in secondary CVD prevention is unclear. Therefore, we studied the association between the presence of a partner, partner participation in lifestyle interventions and LRF modification in patients with coronary artery disease (CAD).

METHODS

In a secondary analysis of the RESPONSE-2 trial (n = 711), which compared nurse-coordinated referral to community-based lifestyle programs (smoking cessation, weight reduction and/or physical activity) to usual care in patients with CAD, we investigated the association between the presence of a partner and the level of partner participation on improvement in >1 LRF (urinary cotinine <200 ng/l, ≥5% weight reduction, ≥10% increased 6-min walking distance) without deterioration in other LRFs at 12 months follow-up.

RESULTS

The proportion of patients with a partner was 80% (571/711); 19% women (108/571). In the intervention group, 48% (141/293) had a participating partner in ≥1 lifestyle program. Overall, the presence of a partner was associated with patients' successful LRF modification (adjusted risk ratio (aRR) 1.93, 95% confidence interval (CI) 1.40-2.51). A participating partner was associated with successful weight reduction (aRR 1.73, 95% CI 1.15-2.35).

CONCLUSION

The presence of a partner is associated with LRF improvement in patients with CAD. Moreover, patients with partners participating in lifestyle programs are more successful in reducing weight. Involving partners of CAD patients in weight reduction interventions should be considered in routine practice.

The Cardiac Care Bridge randomized trial in high-risk older cardiac patients: A mixed-methods process evaluation

Aim

To evaluate healthcare professionals' performance and treatment fidelity in the Cardiac Care Bridge (CCB) nurse‐coordinated transitional care intervention in older cardiac patients to understand and interpret the study results.

Design

A mixed‐methods process evaluation based on the Medical Research Council Process Evaluation framework.

Methods

Quantitative data on intervention key elements were collected from 153 logbooks of all intervention patients. Qualitative data were collected using semi‐structured interviews with 19 CCB professionals (cardiac nurses, community nurses and primary care physical therapists), from June 2017 until October 2018. Qualitative data‐analysis is based on thematic analysis and integrated with quantitative key element outcomes. The analysis was blinded to trial outcomes. Fidelity was defined as the level of intervention adherence.

Results

The overall intervention fidelity was 67%, ranging from severely low fidelity in the consultation of in‐hospital geriatric teams (17%) to maximum fidelity in the comprehensive geriatric assessment (100%). Main themes of influence in the intervention performance that emerged from the interviews are interdisciplinary collaboration, organizational preconditions, confidence in the programme, time management and patient characteristics. In addition to practical issues, the patient's frailty status and limited motivation were barriers to the intervention.

Conclusion

Although involved healthcare professionals expressed their confidence in the intervention, the fidelity rate was suboptimal. This could have influenced the non‐significant effect of the CCB intervention on the primary composite outcome of readmission and mortality 6 months after randomization. Feasibility of intervention key elements should be reconsidered in relation to experienced barriers and the population.

Impact

In addition to insight in effectiveness, insight in intervention fidelity and performance is necessary to understand the mechanism of impact. This study demonstrates that the suboptimal fidelity was subject to a complex interplay of organizational, professionals' and patients' issues. The results support intervention redesign and inform future development of transitional care interventions in older cardiac patients.

Do sex differences in the prevalence of ECG abnormalities vary across ethnic groups living in the Netherlands? A cross-sectional analysis of the population-based HELIUS study

OBJECTIVES

Major ECG abnormalities have been associated with increased risk of cardiovascular disease (CVD) burden in asymptomatic populations. However, sex differences in occurrence of major ECG abnormalities have been poorly studied, particularly across ethnic groups. The objectives were to investigate (1) sex differences in the prevalence of major and, as a secondary outcome, minor ECG abnormalities, (2) whether patterns of sex differences varied across ethnic groups, by age and (3) to what extent conventional cardiovascular risk factors contributed to observed sex differences.

DESIGN

Cross-sectional analysis of population-based study.

SETTING

Multi-ethnic, population-based Healthy Life in an Urban Setting cohort, Amsterdam, the Netherlands.

PARTICIPANTS

8089 men and 11 369 women of Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Turkish and Moroccan origin aged 18-70 years without CVD.

OUTCOME MEASURES

Age-adjusted and multivariable logistic regression analyses were performed to study sex differences in prevalence of major and, as secondary outcome, minor ECG abnormalities in the overall population, across ethnic groups and by age-groups (18-35, 36-50 and >50 years).

RESULTS

Major and minor ECG abnormalities were less prevalent in women than men (4.6% vs 6.6% and 23.8% vs 39.8%, respectively). After adjustment for conventional risk factors, sex differences in major abnormalities were smaller in ethnic minority groups (OR ranged from 0.61 in Moroccans to 1.32 in South-Asian Surinamese) than in the Dutch (OR 0.49; 95% CI 0.36 to 0.65). Only in South-Asian Surinamese, women did not have a lower odds than men (OR 1.32; 95% CI 0.96 to 1.84). The pattern of smaller sex differences in ethnic minority groups was more pronounced in older than in younger age-groups.

CONCLUSIONS

The prevalence of major ECG abnormalities was lower in women than men. However, sex differences were less apparent in ethnic minority groups. Conventional risk factors did not contribute substantially to observed sex differences.

The scientific basis for secondary prevention of coronary artery disease: recent contributions from the Netherlands

While the beneficial effects of secondary prevention of cardiovascular disease are undisputed, implementation remains challenging. A gap between guideline-mandated risk factor targets and clinical reality was documented as early as the 1990s. To address this issue, research groups in the Netherlands have performed several major projects. These projects address innovative, multidisciplinary strategies to improve medication adherence and to stimulate healthy lifestyles, both in the setting of cardiac rehabilitation and at dedicated outpatient clinics. The findings of these projects have led to changes in prevention and rehabilitation guidelines.

Prevalence of ECGs Exceeding Thresholds for ST-Segment-Elevation Myocardial Infarction in Apparently Healthy Individuals: The Role of Ethnicity

Background

Early prehospital recognition of critical conditions such as ST‐segment–elevation myocardial infarction (STEMI) has prognostic relevance. Current international electrocardiographic STEMI thresholds are predominantly based on individuals of Western European descent. However, because of ethnic electrocardiographic variability both in health and disease, there is a need to reevaluate diagnostic ST‐segment elevation thresholds for different populations. We hypothesized that fulfillment of ST‐segment elevation thresholds of STEMI criteria (STE‐ECGs) in apparently healthy individuals is ethnicity dependent.

Methods and Results

HELIUS (Healthy Life in an Urban Setting) is a multiethnic cohort study including 10 783 apparently healthy subjects of 6 different ethnicities (African Surinamese, Dutch, Ghanaian, Moroccan, South Asian Surinamese, and Turkish). Prevalence of STE‐ECGs across ethnicities, sexes, and age groups was assessed with respect to the 2 international STEMI thresholds: sex and age specific versus sex specific. Mean prevalence of STE‐ECGs was 2.8% to 3.4% (age/sex‐specific and sex‐specific thresholds, respectively), although with large ethnicity‐dependent variability. Prevalences in Western European Dutch were 2.3% to 3.0%, but excessively higher in young (<40 years) Ghanaian males (21.7%–27.5%) and lowest in older (≥40 years) Turkish females (0.0%). Ethnicity (sub‐Saharan African origin) and other variables (eg, younger age, male sex, high QRS voltages, or anterolateral early repolarization pattern) were positively associated with STE‐ECG occurrence, resulting in subgroups with >45% STE‐ECGs.

Conclusions

The accuracy of diagnostic tests partly relies on background prevalence in healthy individuals. In apparently healthy subjects, there is a highly variable ethnicity‐dependent prevalence of ECGs with ST‐segment elevations exceeding STEMI thresholds. This has potential consequences for STEMI evaluations in individuals who are not of Western European descent, putatively resulting in adverse outcomes with both over‐ and underdiagnosis of STEMI.

An initial exploration of subtraction electrocardiography to detect myocardial ischemia in the prehospital setting

Background

Methods

Results

Conclusions

Readmission and mortality in patients ≥70 years with acute myocardial infarction or heart failure in the Netherlands: a retrospective cohort study of incidences and changes in risk factors over time

Objectives

To determine the risk of first unplanned all-cause readmission and mortality of patients ≥70 years with acute myocardial infarction (AMI) or heart failure (HF) and to explore which effects of baseline risk factors vary over time.

Methods

A retrospective cohort study was performed on hospital and mortality data (2008) from Statistics Netherlands including 5,175 (AMI) and 9,837 (HF) patients. We calculated cumulative weekly incidences for first unplanned all-cause readmission and mortality during 6 months post-discharge and explored patient characteristics associated with these events.

Results

At 6 months, 20.4% and 9.9% (AMI) and 24.6% and 22.4% (HF) of patients had been readmitted or had died, respectively. The highest incidences were found in week 1. An increased risk for 14-day mortality after AMI was observed in patients who lived alone (hazard ratio (HR) 1.57, 95% confidence interval (CI) 1.01–2.44) and within 30 and 42 days in patients with a Charlson Comorbidity Index ≥3. In HF patients, increased risks for readmissions within 7, 30 and 42 days were found for a Charlson Comorbidity Index ≥3 and within 42 days for patients with an admission in the previous 6 months (HR 1.42, 95% CI 1.12–1.80). Non-native Dutch HF patients had an increased risk of 14-day mortality (HR 1.74, 95% CI 1.09–2.78).

Conclusion

The risk of unplanned readmission and mortality in older AMI and HF patients was highest in the 1st week post-discharge, and the effect of some risk factors changed over time. Transitional care interventions need to be provided as soon as possible to prevent early readmission and mortality.

Electronic supplementary material

The online version of this article (10.1007/s12471-019-1227-4) contains supplementary material, which is available to authorized users.

Ethnic differences in metabolic cardiovascular risk among normal weight individuals: Implications for cardiovascular risk screening. The HELIUS study

BACKGROUND AND AIMS

Cardiovascular disease (CVD) risk factors may occur among a substantial proportion of normal weight individuals, particularly among some ethnic minorities. It is unknown how many of these individuals would be missed by commonly applied eligibility criteria for cardiovascular risk screening. Thus, we aim to determine cardiovascular risk and eligibility for cardiovascular risk screening among normal weight individuals of different ethnic backgrounds.

METHODS AND RESULTS

Using the HELIUS study (Amsterdam, The Netherlands), we determined cardiovascular risk among 6910 normal weight individuals of Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Moroccan and Turkish background. High cardiovascular risk was approximated by high metabolic risk based on blood pressure, HDL, triglycerides and fasting glucose. Eligibility criteria for screening were derived from Dutch CVD prevention guidelines and include age ≥ 50 y, family history of CVD, or current smoking. Ethnic group comparisons were made using logistic regression. Age-adjusted proportions of high metabolic risk ranged from 12.6% to 38.4% (men) and from 2.7% to 11.5% (women). This prevalence was higher among most ethnic minorities than the Dutch, especially among women. For most ethnic groups, 79.9%-86.7% of individuals with high metabolic risk were eligible for cardiovascular risk screening. Exceptions were Ghanaian women (58.8%), Moroccan men (70.9%) and Moroccan women (45.0%), although age-adjusted proportions did not differ between groups.

CONCLUSION

Even among normal weight individuals, high cardiovascular metabolic risk is more common among ethnic minorities than among the majority population. Regardless of ethnicity, most normal weight individuals with increased risk are eligible for cardiovascular risk screening.

Smoking cessation in European patients with coronary heart disease. Results from the EUROASPIRE IV survey: A registry from the European Society of Cardiology

OBJECTIVE

We investigated smoking cessation rates in coronary heart disease (CHD) patients throughout Europe; current and as compared to earlier EUROASPIRE surveys, and we studied characteristics of successful quitters.

METHODS

Analyses were done on 7998 patients from the EUROASPIRE-IV survey admitted for myocardial infarction, unstable angina and coronary revascularisation. Self-reported smoking status was validated by measuring carbon monoxide in exhaled air.

RESULTS

Thirty-one percent of the patients reported being a smoker in the month preceding hospital admission for the recruiting event, varying from 15% in centres from Finland to 57% from centres in Cyprus. Smoking rates at the interview were also highly variable, ranging from 7% to 28%. The proportion of successful quitters was relatively low in centres with a low number of pre- event smokers. Overall, successful smoking cessation was associated with increasing age (OR 1.50; 95% CI 1.09-2.06) and higher levels of education (OR 1.38; 95% CI 1.08-1.75). Successful quitters more frequently reported that they had been advised (56% vs. 47%, p < .001) and to attend (81% vs. 75%, p < .01) a cardiac rehabilitation programme.

CONCLUSION

Our study shows wide variation in cessation rates in a large contemporary European survey of CHD patients. Therefore, smoking cessation rates in patients with a CHD event should be interpreted in the light of pre-event smoking prevalence, and caution is needed when comparing cessation rates across Europe. Furthermore, we found that successful quitters reported more actions to make healthy lifestyle changes, including participating in a cardiac rehabilitation programme, as compared with persistent smokers.

[Limits to the treatment of hypertension]

According to the 2011 Dutch guideline on Cardiovascular risk management 1 in 5 hypertensive patients are eligible for blood pressure lowering treatment. The Dutch guideline recommends striving for a systolic blood pressure (SBP) of < 140 mmHg in adult patients who have no cardiovascular disease or diabetes mellitus, while the recent American guideline now recommends an SBP target value of < 130 mmHg for all adult patients. An important reason for using a stricter SBP target value are the results of randomised studies and meta-analyses that looked at the effect of intensive antihypertensive therapy on the risk of mortality and cardiovascular disease. Based on the literature, there appears to be sufficient evidence that intensive antihypertensive therapy (SBP target value of < 130 mmHg) is useful in patients with cardiovascular disease and in patients with high cardiovascular risk. Currently, there is insufficient evidence that intensive antihypertensive therapy is useful in patients who have diabetes mellitus or who are over 80 years old.

The Association of Acylcarnitines and Amino Acids With Age in Dutch and South-Asian Surinamese Living in Amsterdam

CONTEXT

Type 2 diabetes and cardiovascular disease occur more frequently and at a younger age in South-Asians than Europeans. This may be related to differences in regulation of the fatty acid metabolism during aging. We compared age-related acylcarnitine and amino acid concentrations in Dutch and South-Asian Surinamese study participants.

METHODS

We measured types of acylcarnitine and amino acid concentrations in plasma (by tandem mass spectrometry) in a random subsample of 350 Dutch and 350 South-Asian Surinamese origin participants of the Healthy Life in an Urban Setting study (Amsterdam, Netherlands). We derived principal components (PCs) from the metabolites. Linear regression was used to assess differences in PCs and individual metabolite concentrations, and their age trends between the groups by sex. We adjusted for body mass index and intake of fat and total energy.

RESULTS

Mean age was 44.8 (SD, 13.3) years. Amino acid concentrations were higher among South-Asian Surinamese women compared with Dutch women; acylcarnitine and amino acid levels were higher among South-Asian Surinamese men than Dutch men. Metabolite levels increased similarly with age in both ethnic groups. Results remained similar after adjustment.

CONCLUSION

Ethnic differences in metabolite concentrations suggest that fatty acid and amino acid metabolism are more dysregulated among South-Asian Surinamese compared with Dutch from a young age. During adulthood, metabolites increase similarly in both ethnic groups.

Effects of Primary Cardiovascular Prevention on Vascular Risk in Older Adults

INTRODUCTION

Primary cardiovascular prevention through simultaneously targeting multiple risk factors may be even more effective than single risk factor modification in older adults. The effects of multicomponent cardiovascular prevention on cardiovascular risk are explored.

STUDY DESIGN

Post hoc analysis of the cluster randomized Prevention of Dementia by Intensive Vascular care trial.

SETTING/PARTICIPANTS

Community-dwelling older adults aged 70-78 years, free from cardiovascular disease at baseline (n=2,254, 63.9% of the Prevention of Dementia by Intensive Vascular care trial population).

INTERVENTION

Between 2006 and 2015, the intervention group received nurse-led vascular care every 4 months at the general practitioner practice, the control group received care as usual.

MAIN OUTCOME MEASURES

Cardiovascular disease events and Systematic COronary Risk Evaluation in Older People (SCORE-OP), an index based on six risk factors for cardiovascular mortality. Effects were adjusted for clustering and assessed using mixed effects Cox proportional-hazard models and linear mixed models respectively.

RESULTS

There was no effect of the intervention on cardiovascular disease events (hazard ratio=0.99, 95% CI=0.71, 1.38). During a median follow-up of 6.1 years, SCORE-OP increased from 14.0% and 13.9% to 23.9% and 25.0% in the intervention and control group, respectively (adjusted mean difference in increment in SCORE-OP between the study groups 0.60%, 95% CI= -0.01, 1.20). Exploratory analyses showed a larger reduction of 2.4 mmHg (95% CI=0.9, 3.9) in systolic blood pressure and 1.9% (95% CI=0.4, 3.4) in current cigarette smoking in the intervention group compared with the control group.

CONCLUSIONS

Multicomponent cardiovascular prevention did not improve the overall risk profile in older adults in a primary prevention setting, relative to usual care. However, exploratory analyses showed an effect on blood pressure and smoking cessation. Possibly, contrast between study groups was too small because of the Hawthorne (being part of a study) effect and increasing quality of (preventive) health care for older adults, to yield an effect on the risk profile.

Serial assessment of endothelial function 1, 6, and 12 months after ST-elevation myocardial infarction

Knowledge about the changes in endothelial function after ST-elevation myocardial infarction (STEMI) is of substantial interest, but serial data are scarce. The aim of the present study was to noninvasively evaluate whether endothelial function, as assessed shortly after primary percutaneous coronary intervention (PPCI) for STEMI, may improve until 12-month follow-up. This prospective observational cohort study was performed in patients in the RESPONSE randomized trial who participated in a substudy and underwent noninvasive assessment of endothelial function at 1 (baseline), 6, and 12-month follow-up after treatment of a STEMI by PPCI. The reactive hyperemia peripheral artery tonometry (RH-PAT) method was used to assess endothelial function (higher RH-PAT index signifies better function). Of the 70 study participants, who were 57.4 ± 9.7 years of age, 55 (78.6%) were male and 9 (13%) had diabetes. The endothelial function deteriorated significantly during follow-up: the RH-PAT index at baseline, 6, and 12-month follow-up was 1.90 ± 0.58, 1.81 ± 0.57, and 1.69 ± 0.49, respectively (p = 0.04). Although patients were carefully treated in outpatient clinics and adequate pharmacological therapy was prescribed, we noted an increase in total cholesterol (p = 0.001), LDL cholesterol (p = 0.002), HbA1C (p = 0.054), and diastolic blood pressure (p = 0.047) However, multivariate analysis revealed that this increase in cardiovascular risk factors could not explain the observed deterioration in endothelial function. In patients with STEMI, we observed a significant deterioration in endothelial function during 12 months after PPCI that could not be explained by changes in the traditional cardiovascular risk profile.

The cardiac care bridge program: design of a randomized trial of nurse-coordinated transitional care in older hospitalized cardiac patients at high risk of readmission and mortality

BACKGROUND

After hospitalization for cardiac disease, older patients are at high risk of readmission and death. Although geriatric conditions increase this risk, treatment of older cardiac patients is limited to the management of cardiac diseases. The aim of this study is to investigate if unplanned hospital readmission and mortality can be reduced by the Cardiac Care Bridge transitional care program (CCB program) that integrates case management, disease management and home-based cardiac rehabilitation.

METHODS

In a randomized trial on patient level, 500 eligible patients ≥ 70 years and at high risk of readmission and mortality will be enrolled in six hospitals in the Netherlands. Included patients will receive a Comprehensive Geriatric Assessment (CGA) at admission. Randomization with stratified blocks will be used with pre-stratification by study site and cognitive status based on the Mini-Mental State Examination (15-23 vs ≥ 24). Patients enrolled in the intervention group will receive a CGA-based integrated care plan, a face-to-face handover with the community care registered nurse (CCRN) before discharge and four home visits post-discharge. The CCRNs collaborate with physical therapists, who will perform home-based cardiac rehabilitation and with a pharmacist who advices the CCRNs in medication management The control group will receive care as usual. The primary outcome is the incidence of first all-cause unplanned readmission or mortality within 6 months post-randomization. Secondary outcomes at three, six and 12 months after randomization are physical functioning, functional capacity, depression, anxiety, medication adherence, health-related quality of life, healthcare utilization and care giver burden.

DISCUSSION

This study will provide new knowledge on the effectiveness of the integration of geriatric and cardiac care.

TRIAL REGISTRATION

NTR6316 . Date of registration: April 6, 2017.

Effects of Postacute Multidisciplinary Rehabilitation Including Exercise in Out-of-Hospital Settings in the Aged: Systematic Review and Meta-analysis

OBJECTIVE

Many older individuals receive rehabilitation in an out-of-hospital setting (OOHS) after acute hospitalization; however, its effect on mobility and unplanned hospital readmission is unclear. Therefore, a systematic review and meta-analysis were conducted on this topic.

DATA SOURCES

Medline OVID, Embase OVID, and CINAHL were searched from their inception until February 22, 2018.

STUDY SELECTION

OOHS (ie, skilled nursing facilities, outpatient clinics, or community-based at home) randomized trials studying the effect of multidisciplinary rehabilitation were selected, including those assessing exercise in older patients (mean age ≥65y) after discharge from hospital after an acute illness.

DATA EXTRACTION

Two reviewers independently selected the studies, performed independent data extraction, and assessed the risk of bias. Outcomes were pooled using fixed- or random-effect models as appropriate. The main outcomes were mobility at and unplanned hospital readmission within 3 months of discharge.

DATA SYNTHESIS

A total of 15 studies (1255 patients) were included in the systematic review and 12 were included in the meta-analysis (7 assessing mobility using the 6-minute walk distance [6MWD] test and 7 assessing unplanned hospital readmission). Based on the 6MWD, patients receiving rehabilitation walked an average of 23 m more than controls (95% confidence interval [CI]=: -1.34 to 48.32; I²: 51%). Rehabilitation did not lower the 3-month risk of unplanned hospital readmission (risk ratio: 0.93; 95% CI: 0.73-1.19; I²: 34%). The risk of bias was present, mainly due to the nonblinded outcome assessment in 3 studies, and 7 studies scored this unclearly.

CONCLUSION

OOHS-based multidisciplinary rehabilitation leads to improved mobility in older patients 3 months after they are discharged from hospital following an acute illness and is not associated with a lower risk of unplanned hospital readmission within 3 months of discharge. However, the wide 95% CIs indicate that the evidence is not robust.

Increased cardiovascular disease risk in international migrants is independent of residence duration or cultural orientation: the HELIUS study

BACKGROUND

International migrants differ from host populations in cardiovascular disease (CVD) risk. It has been postulated that these disparities narrow with longer residence duration. Our aim was to determine whether CVD risk still differs between migrants and host population after decades of residence and to determine whether this potential convergence of CVD risk would occur mainly among migrants with a strong cultural orientation towards the host culture.

METHODS

In the Healthy Life in an Urban Setting study, we obtained data regarding residence duration, cultural orientation as estimated by the Psychological Acculturation Scale and CVD risk as estimated by SCORE among the Dutch host population and first generation migrants from South-Asian Surinamese, African Surinamese, Moroccan and Turkish ethnic background residing in Amsterdam. Estimated CVD risk was compared with the Dutch, separately for medium-term residence (15-30 years) or long-term residence (>30 years) migrants, and by strong/weak cultural orientation towards the Dutch culture, using age-adjusted regression analyses.

RESULTS

Among 8672 participants without prior CVD, estimated CVD risk was higher among migrant groups relative to the Dutch. CVD risk relative to the Dutch did not differ by residence duration (betas ranging from 0.1 to 3.4 for medium-term and from 0.6 to 3.3 for long-term residence, respectively). Furthermore, these patterns did not differ by cultural orientation towards the Dutch culture.

CONCLUSION

We find no indication that CVD risk among South-Asian Surinamese, African Surinamese, Turkish or Moroccan migrants converges to that of the Dutch host population with increasing residence duration, not even among those with strong cultural orientation towards the host culture.