Systematic Review on the Cost Effectiveness of Prostate Cancer Screening in Europe

BACKGROUND AND OBJECTIVE

In Europe, prostate cancer (PCa) is the most common cancer in men. Screening may therefore be crucial to lower health care costs, morbidity, and mortality. This systematic review aimed to provide a contemporary overview of the costs and benefits of PCa screening programmes.

METHODS

A peer-reviewed literature search was conducted, using the PICO method. A detailed search strategy was developed in four databases based on the following key search terms: "PCa", "screening", and "cost effectiveness". Any type of economic evaluation was included. The search strategy was restricted to European countries, but no restrictions were set on the year of publication.

KEY FINDINGS AND LIMITATIONS

A total of 7484 studies were identified initially. Of these, 19 studies described the cost effectiveness of PCa screening in Europe. Among the studies using an initially healthy study population, most focussed on risk- and/or age- and/or magnetic resonance imaging (MRI)-based screening in addition to prostate-specific antigen (PSA) testing and compared this with no screening. Incremental cost ratios (ICERs) varied from €5872 per quality-adjusted life year (QALY) to €372 948/QALY, with a median of €56 487/QALY. Risk-based screening followed by MRI testing seemed to be a more cost-effective strategy than no screening.

CONCLUSIONS AND CLINICAL IMPLICATIONS

This systematic review indicates that screening programmes incorporating a risk-based approach and MRI have the potential to be cost effective.

PATIENT SUMMARY

In this review, we looked at the cost effectiveness of prostate cancer screening in Europe. We found that a risk-based approach and incorporation of magnetic resonance imaging has the potential to be cost effective. However, there remains a knowledge gap regarding cost effectiveness of prostate cancer screening. Therefore, determinants of cost effectiveness require further investigation.

Health Policy for Prostate Cancer Early Detection in the European Union and the Impact of Opportunistic Screening: PRAISE-U Consortium

With the new policy recommendation in 2022 to explore the possibilities of screening for prostate cancer by the European Commission, the landscape for prostate cancer early detection is evolving. In line with this recommendation, the PRAISE-U project aims to evaluate the early detection and diagnosis of prostate cancer through customised and risk-based screening programmes, with the goal to align protocols across European Union member states. This systematic review is part of the PRAISE-U project, with the goal to review the policy, medical guideline recommendations, and the current level of opportunistic screening presented in the scientific literature on prostate cancer early detection from 2016 to 2023 in European Union member states. An extensive literature search was performed on 1 June 2023 in a large number of databases, including Embase.com, Medline (Ovid), Web of Science Core Collection, Google Scholar, and Policy Commons. We identified 318 articles (qualitative, quantitative, and reviews), of which 41 were included in the full-text screening. Seventeen articles were ultimately identified as eligible for inclusion. The included articles revealed significant variations towards PSA-based early detection policies for prostate cancer in nine European countries. Despite official recommendations, opportunistic screening was prevalent across all nine countries regardless of recommendations for or against PSA-based early detection. This systematic review suggests that the current early detection policies are not fit for purpose. High levels of opportunistic screening and overdiagnosis persist, prompting policy recommendations for standardised guidelines, informed decision making, and increased awareness to improve efficiency and effectiveness in early detection.

Gender differences in risk factor management and pharmacological treatment among CHD patients: Belgian results of the EUROASPIRE IV and EUROASPIRE V surveys

AIMS

The aim of this study was to provide an up-to-date overview of gender differences or similarities in risk factor control and medical management in the Belgian CHD population.

METHODS

All analyses are based on the ESC EORP EUROASPIRE IV and EUROASPIRE V (European Survey Of Cardiovascular Disease Prevention And Diabetes) surveys. Patients between 18 and 80 years old, hospitalised for a first or recurrent coronary event, were included in the survey.

RESULTS

Data were available for 10,519 patients, of which 23.9% were women. Women had a worse risk factor profile compared to men. Women were more physical inactive (OR = 1.31, 95% CI = 1.19-1.44), had a higher prevalence of obesity (OR = 1.37, 95% CI = 1.25-1.50) and had a worse LDL-C control (OR = 1.52, 95% CI = 1.36-1.70). Moreover, women were less likely to use ACE-I/ARBs (OR = 0.84, 95% CI = 0.76-0.94) and statins (OR = 0.79, 95% CI = 0.70-0.90). In addition, little gender differences were found in patients' risk factor awareness, except on cholesterol awareness. Women were more aware about their total cholesterol levels (OR = 1.37, 95% CI = 1.21-1.56).

CONCLUSION

Despite little to no gender differences in the management of CHD patients, women still have a worse risk factor profile, both in Belgian and in other European high-income countries.

Gender differences in health-related quality of life and psychological distress among coronary patients: Does comorbidity matter? Results from the ESC EORP EUROASPIRE V registry

AIMS

This study aimed to provide an overview on contemporary gender differences in HRQoL/psychological distress and their relationship with comorbidity burden among European coronary heart disease (CHD) patients.

METHODS

Analyses were based on the cross-sectional ESC EORP EUROASPIRE V survey. Consecutive patients (aged 18-80 years), hospitalized for a first or recurrent coronary event were included in this study. Data at hospital discharge and at follow-up (6 to 24 months after hospitalisation) were collected.

RESULTS

Data were available for 8261 patients of which 25.8% women. Overall, women reported a worse EQ-5D-5L index score (0.73 vs. 0.81; P < 0.001), EQ-VAS (63.1 vs. 66.0; P = 0.001), global HeartQoL (1.94 vs. 2.26; P < 0.001), physical HeartQoL (1.96 vs. 2.30; P < 0.001), emotional HeartQoL (1.88 vs. 2.18; P < 0.001), HADS-A (6.69 vs. 4.99; P < 0.001), and HADS-D (5.73 vs. 4.62; P < 0.001) compared to men. Also, women were more likely to have comorbidities compared to men (1 comorbidity: 38.7% vs. 35.0%, 2 comorbidities: 9.7% vs. 7.5%; P < 0.001). There is indication that heart failure (EQ-VAS) and diabetes (global HeartQoL, emotional HeartQoL, physical HeartQoL, and HADS-D) interacted with gender and modulate the relationship with HRQoL, in disfavour of women.

CONCLUSION

Substantial gender-based health inequalities in terms of HRQoL and psychological distress were found, in disfavour of women. Women had worse HRQoL and psychological distress outcomes when having comorbidities. To a limited extent, comorbidity and women had a negative/synergistic effect on HRQoL. Special attention should be given to this population groups within daily clinical practice.

Gender differences in cardiovascular risk factor awareness. Results from the ESC EORP EUROASPIRE V registry

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Fonds voor hartchirurgie - Fonds pour la Chirurgie Cardiaque

Background

Risk factor awareness among coronary patients is related to a decreased risk of recurrent coronary events and hence important in the secondary prevention of coronary heart disease (CHD). Whereas previous studies demonstrated gender differences in disfavour of women with regard to patients’ risk factor control, little is known about gender differences in patients’ risk factor awareness.

Purpose

The aim of this study was to document potential gender differences across Europe in patients’ risk factor awareness and information provided by healthcare professionals.

Methods

Analyses were based on data from the most recent ESC EORP EUROASPIRE V survey (European Survey Of Cardiovascular Disease Prevention And Diabetes, 2016-17). Consecutive patients hospitalized for a first or recurrent coronary event or surgical procedure between 18-80 years old at the time of identification were retrospectively identified in 27 countries. Awareness of risk factor levels were defined as patients’ self-reported awareness about their latest weight, waist circumference, blood pressure, total cholesterol, blood glucose levels, and HbA1c levels. Data on risk factor awareness and information provided by healthcare professionals were obtained from patient interviews (6 months to 2 years prior to the date of the study visit). Logistic regression analyses were performed adjusting for age and medical history (stroke, heart failure, and diabetes).

Results

Information was available on 8,261 patients, including 25.8% women. Women were significantly older (65.4 vs. 63.0 years) and were more likely to have a history of stroke (5.3% vs. 3.7%; P=0.002), heart failure (7.6% vs. 5.9%; P=0.006), and self-reported diabetes (33.1% vs. 28.0%; P&lt;0.001). Overall, no significant gender differences were found regarding the information provided by a healthcare professional on overweight, diabetes, and chronic kidney disease, whereas, a higher proportion of women with hypertension (≥140/80 (≥140/85 if diabetes)) (OR=2.07, 95% CI=4.60-2.68) and women with raised cholesterol levels (LDL-C ≥1.8mmol/L) (OR=1.31, 95% CI=1.14-1.51) were informed about their raised risk factor levels. Furthermore, women with obesity were less aware about their actual weight (OR= 0.66, 95% CI=0.52-0.85) and weight target level (OR= 0.66, 95% CI=0.54-0.81) than men. In contrast, no significant gender differences in awareness of waist circumference levels were found in obese patients neither for fasting blood glucose or HbA1c levels in patients with self-reported diabetes. Women with hypertension and those found with raised LDL-C levels were more aware about their target blood pressure level (OR=1.21, 95% CI=1.01-1.46) and actual cholesterol level (OR=1.18, 95% CI=1.02-1.36).

Conclusions

Our study reveals only little gender differences in disfavour of women in terms of information provided by healthcare professionals and risk factor awareness.

Gender differences in health-related quality of life among coronary patients and the relation with comorbidity burden. Results from the ESC EORP EUROASPIRE V survey

Background

Impaired health-related quality of life (HRQoL) is related to increased morbidity and mortality among coronary heart disease (CHD) patients. Although gender differences in HRQoL have been observed in the general population, the magnitude of gender differences tends to be more pronounced in CHD patients. In addition, a higher comorbidity burden, common in CHD patients, is known to result in an even worse HRQoL outcome.

Purpose

The aim of this study is to evaluate HRQoL- gender differences among CHD patients and to explore its relationship with comorbidity burden.

Methods

Analyses were based on the most recent ESC EORP EUROASPIRE V survey data, including patient information from 27 European countries. Consecutive patients (18–80 years), hospitalized for a coronary event or surgical procedure were recruited in the survey. Data presented here were obtained from medical records and standardized patient interviews (6 months to 2 years following hospital discharge). Mean EQ-5D-5L index scores were used to evaluate patients' self-reported health status. A history of stroke, heart failure, peripheral artery disease (PAD), chronic kidney disease (CKD), and self-reported diabetes were considered as comorbidities. Generalized linear mixed models were fitted accounting for clustering of patients within countries and adjusted for age. To investigate the interplay of gender with comorbidities, two-way interaction terms were included.

Results

Data was available for 8,261 patients, including 25.8% women. Women were slightly older than men (65.4 vs 63.0 years) and more likely to have a history of stroke (5.3% vs. 3.7%; p=0.04), heart failure (7.6% vs. 5.9%; p=0.02), and self-reported diabetes (33.1% vs. 28.0%; p&lt;0.001). No significant differences were seen in the prevalences of PAD (2.5% vs. 2.7%; p=0.25) and CKD (13.8% vs. 14.5%; p=0.47). Overall, women reported a worse EQ-5D-5L index score compared to men (0.73 vs. 0.81; p&lt;0.001). Also, considering CHD patients without comorbidities, women reported a worse EQ-5D-5L index score (0.77 vs. 0.84; p&lt;0.001). Stratification by comorbidities revealed that the EQ-5D-5L index score differed substantially between genders. Although no gender differences were found for patients with PAD (0.62 vs. 0.68; p=0.13), women reported a worse EQ-5D-5L index score if having a history of stroke (0.59 vs. 0.69; p&lt;0.001), heart failure (0.64 vs. 0.71; p=0.01), CKD (0.76 vs. 0.81; p&lt;0.001), and self-reported diabetes (0.69 vs. 0.78; p&lt;0.001). Moreover, detailed analyses revealed a significant interaction between gender and self-reported diabetes (p=0.04) and gender and CKD (p=0.04) in favour of women. A closer look at the combination of comorbidities revealed no significant interactions possibly due to the smaller number of patients.

Conclusion

Women reported a worse HRQoL compared to men. Further quantitative and qualitative research is needed to understand the gender-differential in HRQoL.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Fonds voor hartchirurgie - Fonds pour la Chirurgie Cardiaque

Lifestyle management and compliance in coronary patients: The gender gap. Results from the ESC EORP EUROASPIRE V survey

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Fonds voor hartchirurgie - Fonds pour la Chirurgie Cardiaque

OnBehalf

EUROASPIRE studygroup

BACKGROUND

Although previous EUROASPIRE (European Survey Of Cardiovascular Disease Prevention And Diabetes) findings suggest only limited gender differences in the medication intake of coronary patients, the CVD risk factor profile in women remains suboptimal compared to men. Therefore, to further lower the risk of subsequent cardiovascular events, lifestyle behaviour in secondary prevention is crucial. Little is known about gender differences in prescribed lifestyle and patient compliance in tackling lifestyle related risk factor targets.

PURPOSE

The aim of this study is to identify gender differences in lifestyle prescription and lifestyle compliance after a coronary event.

METHODS

Analyses were carried out on the ESC EORP EUROASPIRE V survey data, including information from coronary patients recruited in 27 European countries. Consecutive patients &lt;80 years were hospitalized for a CABG, PCI, acute myocardial infarction or acute myocardial ischaemia. Information on lifestyle prescription and lifestyle compliance, were obtained from standardized patient interviews (6 months to 2 years following hospital discharge). Logistic regression analyses adjusting for medical history (stroke, heart failure and diabetes) were performed.

RESULTS

Data was available for 8261 patients of which 25.8% were women. The mean (SD) age at interview was 62.9 (9.7) years for men and 65.4 (9.2) for women. Overall, no gender differences were observed in smoking cessation advice (85.2% vs. 84.5%; P = 0.90) and in smokers’ attempts to quit smoking (62.6% vs. 63.9%; P= 0.58). Also, no gender differences were observed in dietary advice (85.5% vs. 84.9%; P= 0.32) and in attempts to adopt a healthier diet (87.1% vs. 88.4%; P= 0.14). In contrast, although no gender differences were seen in weight changes among obese patients (60.1% vs. 58.2%; P = 0.49), women were less likely to receive advice on losing weight (75.1% vs. 71.6%; P = 0.02). Interestingly,  the latter findings were driven by educational level. Women with a low education level were less likely to receive weight loss advice (71.8% vs. 52.9%; P &lt; 0.001) and a lower proportion of them tried to lose weight (52.3% vs. 36.7%; P &lt; 0.001), while no significant differences were observed in those with a high educational level. Furthermore, women were less likely to receive physical activity advice (63.8% vs. 59.6%; P &lt; 0.001) and a lower proportion of them attempted to increase their physical activity levels (55.5% vs. 48.0%; P &lt; 0.001).

CONCLUSION

These findings suggest worse lifestyle prescription and lifestyle changes for physical activity in women and worse weight loss prescription and weight loss compliance in low educated but not highly educated women. Specific attention should be given to women with a low educational level. Further quantitative and qualitative research is needed to understand the gender gap in lifestyle management.

Sexual counselling in patients with heart failure: Perceptions and current practice by healthcare providers in Flanders

BACKGROUND

Although heart failure (HF) patients often consider sexual activity as an essential aspect of their quality of life (QoL) and are usually uncertain if it is safe to perform sexual activity, this topic is overall poorly addressed in clinical practice.

AIMS

The aim of this study was to explore the perceptions and practices of Flemish caregivers.

METHODS

Healthcare providers were recruited through convenience sampling and filled in an adapted version of the UNITE Sexual Counselling Instrument. Several relevant network structures in Flanders were used to distribute the questionnaires-online as well as on paper-to healthcare workers being involved in the care to HF patients.

RESULTS

Results of 180 participants indicated that 51.5% of the healthcare providers have never provided sexual counselling in HF patients. Being male, having a masters' degree, having more than 10 years of experience in cardiovascular disease, working in an ambulatory care department and having more positive attitudes were independently associated with a higher provision of sexual counselling in practice.

CONCLUSION

Although healthcare providers perceive it as their responsibility to discuss patients' sexual concerns, these issues are not often addressed in daily practice. Increasing knowledge in healthcare providers and specific practical training in providing information on sexual activity in HF patients are recommended. Further studies are needed to investigate how sexual counselling can be provided in agreement with HF patients' expectations and needs.

Gender differences in screening for glucose perturbations, cardiovascular risk factor management and prognosis in patients with dysglycaemia and coronary artery disease: results from the ESC-EORP EUROASPIRE surveys

Background

Gender disparities in the management of dysglycaemia, defined as either impaired glucose tolerance (IGT) or type 2 diabetes (T2DM), in coronary artery disease (CAD) patients are a medical challenge. Recent data from two nationwide cohorts of patients suggested no gender difference as regards the risk for diabetes-related CV complications but indicated the presence of a gender disparity in risk factor management. The aim of this study was to investigate gender differences in screening for dysglycaemia, cardiovascular risk factor management and prognosis in dysglycemic CAD patients.

Methods

The study population (n = 16,259; 4077 women) included 7998 patients from the ESC-EORP EUROASPIRE IV (EAIV: 2012–2013, 79 centres in 24 countries) and 8261 patients from the ESC-EORP EUROASPIRE V (EAV: 2016–2017, 131 centres in 27 countries) cross-sectional surveys. In each centre, patients were investigated with standardised methods by centrally trained staff and those without known diabetes were offered an oral glucose tolerance test (OGTT). The first of CV death or hospitalisation for non-fatal myocardial infarction, stroke, heart failure or revascularization served as endpoint. Median follow-up time was 1.7 years. The association between gender and time to the occurrence of the endpoint was evaluated using Cox survival modelling, adjusting for age.

Results

Known diabetes was more common among women (32.9%) than men (28.4%, p < 0.0001). OGTT (n = 8655) disclosed IGT in 17.2% of women vs. 15.1% of men (p = 0.004) and diabetes in 13.4% of women vs. 14.6% of men (p = 0.078). In both known diabetes and newly detected dysglycaemia groups, women were older, with higher proportions of hypertension, dyslipidaemia and obesity. HbA1c was higher in women with known diabetes. Recommended targets of physical activity, blood pressure and cholesterol were achieved by significantly lower proportions of women than men. Women with known diabetes had higher risk for the endpoint than men (age-adjusted HR 1.22; 95% CI 1.04–1.43).

Conclusions

Guideline-recommended risk factor control is poorer in dysglycemic women than men. This may contribute to the worse prognosis in CAD women with known diabetes.

Gender gap in risk factor control of coronary patients far from closing: results from the European Society of Cardiology EUROASPIRE V registry

AIMS

This study aims to provide an overview on contemporary gender differences in the risk factor control of coronary heart disease (CHD) patients.

METHODS AND RESULTS

Analyses were based on the cross-sectional ESC (European Society of Cardiology) EORP (EurObservational Research Programme) EUROASPIRE V (European Survey of Cardiovascular Disease Prevention and Diabetes) survey including data on CHD patients across 27 European countries. Men and women between 18 and 80 years old, hospitalized for a first or recurrent coronary event were included in the study. Data were available for 8261 patients of which 25.8% women. Overall, women had a worse risk factor control compared with men. Whereas women were more likely to be non-smokers (79.3% vs. 87.2%; P < 0.001), they were less likely to reach recommended levels of physical activity (36.8% vs. 27.5%; P < 0.001), and they were less likely to be non-obese (65.1% vs. 54.3%; P < 0.001). There is indication that risk factors such as smoking behaviour and obesity differed depending on country income level. No gender differences could be observed in blood pressure on target (P > 0.05). Moreover, a lower proportion of women reached low-density lipoprotein cholesterol (LDL-C) target levels (31.4% vs. 22.1%; P < 0.001), and they were less likely to reach glycated haemoglobin (HbA1c) targets if having self-reported diabetes (56.7% vs. 48.6%; P < 0.001).

CONCLUSION

The risk factor control of CHD women is substantial worse compared with men despite little gender differences in cardiovascular medication intake. Further actions are needed to increase the awareness of the worse risk factor control in female CHD patients.

Risk factor management in coronary patients: results from the EUROASPIRE V survey

Background

Previously, there has been a misperception that cardiovascular disease (CVD) mainly affects males. Although lately, there is increasing awareness about the risk of CVD in women, evidence suggests that the management of women with CVD is suboptimal.

Purpose

The aim of this study is to look at gender differences in treatment and risk factor control after a coronary event across countries with varying income levels.

Methods

Analyses were based on the ESC-EORP EUROASPIRE V survey, including patient information from 27 European countries. Patients included (18–80 years), were hospitalised for an ischaemic coronary event. Information on medical treatment, risk factors and behavioural changes were obtained during patient interviews (6 months to 2 years after hospitalization). Findings on treatment and risk factor control were compared with the European guidelines on CVD prevention (2016). Country classification by income level (low/medium income vs. high income) was done according to the World Bank Atlas method. Logistic regression analyses adjusted for sex, age, education level, country income, surgical intervention, stroke, heart failure and diabetes were performed.

Results

Data from 8261 coronary patients, of which 25.8% women, were included in the analyses. Mean (SD) age at the interview was 62.95 (9.72) years for men and 65.36 (9.21) years for women. First, when looking at the evidence based medication intake, no gender differences were seen in the prescription of antiplatelets/aspirin, whereas statins were more often prescribed in men (82.8% vs. 77.7%; p=0.002). A closer look by country income revealed that this difference is entirely due to the higher statin use among men from low/medium income countries (79.6% vs. 72.3%; p=0.004). Second, the risk factor profile differed substantially between genders. Overall, a worse risk factor profile was seen in women. Although, men were more likely to smoke (20.7% vs. 12.8%; p&lt;0.001), women were less physically active (63.2% vs. 72.5%; p&lt;0.001), had more obesity (34.9% vs. 45.7%; p&lt;0.001) and central obesity (51.8% vs. 78.0%; p&lt;0.001), and had a worse lipid control (65.9% vs. 74.3%; p&lt;0.001). Overall, no gender differences were seen in diabetes prevalence and blood pressure control. A closer look at country income level showed that the gender difference in smoking prevalence dissolved in high income countries. In addition, women in low income countries were more likely to suffer from diabetes (26.7% vs. 38.9%; p&lt;0.001).

Conclusion

These findings suggest a worse risk factor profile in women despite little to no gender differences in medical treatment. Further research is needed to understand the gender-differential in risk factor control.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Fonds voor hartchirurgie - Fonds pour la Chirurgie Cardiaque

Medical Treatment in Coronary Patients: Is there Still a Gender Gap? Results from European Society of Cardiology EUROASPIRE V Registry

PURPOSE

This study is aimed at investigating gender differences in the medical management of patients with coronary heart disease (CHD).

METHODS

Analyses were based on the ESC EORP EUROASPIRE V (European Survey Of Cardiovascular Disease Prevention And Diabetes) survey. Consecutive patients between 18 and 80 years, hospitalized for a coronary event, were included in the study. Information on cardiovascular medication intake at hospital discharge and at follow-up (≥ 6 months to < 2 years after hospitalization) was collected.

RESULTS

Data was available for 8261 patients (25.8% women). Overall, no gender differences were observed in the prescription and use of cardioprotective medication like aspirin, beta-blockers, and ACE-I/ARBs (P > 0.01) at discharge and follow-up respectively. However, a statistically significant difference was found in the use of statins at follow-up, in disfavor of women (82.8% vs. 77.7%; P < 0.001). In contrast, at follow-up, women were more likely to use diuretics (31.5% vs. 39.5%; P < 0.001) and calcium channel blockers (21.2% vs. 28.8%; P < 0.001), whereas men were more likely to use anticoagulants (8.8% vs. 7.0%; P < 0.001). Overall, no gender differences were found in total daily dose intake (P > 0.01). Furthermore, women were less likely than men to have received a CABG (20.4% vs. 13.2%; P < 0.001) or PCI (82.1% vs. 74.9%; P < 0.001) at follow-up. No gender differences were observed in prescribed (P = 0.10) and attended (P = 0.63) cardiac rehabilitation programs.

CONCLUSION

The EUROASPIRE V results show only limited gender differences in the medical management of CHD patients. Current findings suggest growing awareness about risk in female CHD patients.

Socioeconomic characteristics of patients with coronary heart disease in relation to their cardiovascular risk profile

OBJECTIVE

People's socioeconomic status (SES) has a major impact on the risk of atherosclerotic cardiovascular disease (ASCVD) in primary prevention. In patients with existing ASCVD these associations are less documented. Here, we evaluate to what extent SES is still associated with patients' risk profile in secondary prevention.

METHODS

Based on results from a large sample of patients with coronary heart disease from the European Action on Secondary and Primary Prevention through Intervention to Reduce Events study, the relationship between SES and cardiovascular risk was examined. A SES summary score was empirically constructed from the patients' educational level, self-perceived income, living situation and perception of loneliness.

RESULTS

Analyses are based on observations in 8261 patients with coronary heart disease from 27 countries. Multivariate logistic regression analyses demonstrate that a low SES is associated (OR, 95% CI) with lifestyles such as smoking in men (1.63, 1.37 to 1.95), physical activity in men (1.51, 1.28 to 1.78) and women (1.77, 1.32 to 2.37) and obesity in men 1.28 (1.11 to 1.49) and women 1.65 (1.30 to 2.10). Patients with a low SES have more raised blood pressure in men (1.24, 1.07 to 1.43) and women (1.31, 1.03 to 1.67), used less statins and were less adherent to them. Cardiac rehabilitation programmes were less advised and attended by patients with a low SES. Access to statins in middle-income countries was suboptimal leaving about 80% of patients not reaching the low-density lipoprotein cholesterol target of <1.8 mmol/L. Patients' socioeconomic level was also strongly associated with markers of well-being.

CONCLUSION

These results illustrate the complexity of the associations between SES, well-being and secondary prevention in patients with ASCVD. They emphasise the need for integrating innovative policies in programmes of cardiac rehabilitation and secondary prevention.