European guidelines on cardiovascular disease prevention in clinical practice Third Joint Task Force of European and other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of eight societies and by invited experts)

Lower extremity peripheral artery disease in the absence of traditional risk factors. The Multi-Ethnic Study of Atherosclerosis

OBJECTIVE

Lower-extremity peripheral artery disease (LE-PAD), is strongly related to traditional risk factors (smoking, hypertension, dyslipidemia, diabetes). We hypothesized that the prevalence of LE-PAD in the absence of traditional CVD risk factors is not negligible, and that this condition would remain associated with subclinical atherosclerosis in other territories.

METHODS

In the Multi-Ethnic Study of Atherosclerosis, we classified participants without any traditional risk factor according to their ankle-brachial index (ABI) into 3 groups: low (<1.00), normal (1.00-1.30) and high (>1.30) ABI. Coronary or carotid artery diseases were defined by the presence of any coronary artery calcification (CAC score>0) or carotid plaque, respectively.

RESULTS

Among the 6814 participants, 1932 had no traditional risk factors. A low- and high ABI were found in 176 (9%) and 149 (7.8%) cases, respectively. Lower glomerular filtration rate (OR: 0.88/10 units, p=0.04) and higher Interleukin-6 levels (OR: 1.42/natural-log unit, p=0.02) were associated with low ABI. Past smoking (cessation>10 years) and pulse pressure had borderline association with low ABI. In adjusted models, low-ABI was significantly associated with CAC prevalence (OR: 1.22, p<0.03). No significant association was found with carotid plaque.

CONCLUSION

In the absence of traditional CVD risk factors, LE-PAD is still common and associated with coronary artery disease.

Screening families of patients with premature coronary heart disease to identify avoidable cardiovascular risk: a cross-sectional study of family members and a general population comparison group

Background

Primary prevention should be targeted at individuals with high global cardiovascular risk, but research is lacking on how best to identify such individuals in the general population. Family history is a good proxy measure of global risk and may provide an efficient mechanism for identifying high risk individuals. The aim was to test the feasibility of using patients with premature cardiovascular disease to recruit family members as a means of identifying and screening high-risk individuals.

Findings

We recruited family members of 50 patients attending a cardiology clinic for premature coronary heart disease (CHD). We compared their cardiovascular risk with a general population control group, and determined their perception of their risk and current level of screening. 103 (36%) family members attended screening (27 siblings, 48 adult offspring and 28 partners). Five (5%) had prevalent CHD. A significantly higher percentage had an ASSIGN risk score >20% compared with the general population (13% versus 2%, p < 0.001). Only 37% of family members were aware they were at increased risk and only 50% had had their blood pressure and serum cholesterol level checked in the previous three years.

Conclusions

Patients attending hospital for premature CHD provide a mechanism to contact family members and this can identify individuals with a high global risk who are not currently screened.

Gender-specific association of psychological distress with cardiovascular risk scores

OBJECTIVE

To examine the gender differences in the association of psychological distress with cardiovascular disease (CVD) risk scores using two different CVD risk assessment models.

DESIGN AND SETTING

A cross-sectional, population-based study from 1997 to 1998 in Pieksämäki, Finland.

SUBJECTS

A population sample of 899 (399 male and 500 female) middle-aged subjects.

MAIN OUTCOME MEASURES

The 10-year risk for CVD events was calculated using the European SCORE model and the Framingham CVD risk prediction model. Psychological distress was measured using the 12-item General Health Questionnaire (GHQ-12). Study subjects were allocated into three groups according to their global GHQ-12 -scores: 0 points, 1-2 points, and 3-12 points.

RESULTS

Psychological distress was associated with higher mean CVD risk scores in men. Men in the highest GHQ group (3-12 points) had significantly higher mean European CVD risk score (3.6 [SD 3.3]) compared with men in the lowest group (0 points) (2.5 [SD 2.6]), the difference being 1.1 (95% CI 0.4 to 1.9). The p-value for linearity between the three GHQ groups was 0.003. The Framingham CVD risk prediction model yielded similar results: 15.7 (SD 10.2) vs. 12.3 (SD 9.6), the difference 3.4 (95% CI 1.0 to 6.0) and p-value for linearity 0.008. No significant association was observed in women.

CONCLUSION

A gender-specific association was found between psychological distress and cardiovascular risk scores. These results highlight the importance of identifying men with psychological distress when assessing CVD risk.

Age- and gender-specific awareness, treatment, and control of cardiovascular risk factors and subclinical vascular lesions in a founder population: the SardiNIA Study

AIM

We investigated the gender-specific control of cardiovascular (CV) risk factors and subclinical vascular lesions in a founder population in Italy.

METHODS AND RESULTS

6148 subjects were enrolled (aged 14-102 years) from four towns. Hypertension (HT), diabetes mellitus (DM) and dyslipidemia (LIP) were defined in accordance with guidelines. A self-reported diagnosis defined awareness of these conditions, and the current use of specific medications as treatment. Prevalence was HT 29.2%, DM 4.8%, LIP 44.1% and was higher in men than in women. Disease prevalence increased with age for every CV risk factor. Men were less likely than women to take anti-HT drugs and to reach BP control (9.9% vs. 16%). Only 17.6% of HT > 65 years had a BP < or =140/90 mmHg, though 48.5% were treated. The use of statins was very low (<1/3 of eligible subjects > 65 years, those with the highest treatment rate). The ratio of control-to-treated HT was lower in subjects with, than in those without, thicker carotid arteries (31.5% vs. 38.8%, p < 0.05) or stiffer aortas (26.0% vs. 40.0%, p < 0.05) or carotid plaques (26.3% vs. 41.1%, p<0.05).

CONCLUSION

A large number of subjects at high CV risk are not treated and the management of subclinical vascular lesions is far from optimal.

[European Guidelines on Cardiovascular Disease Prevention in Clinical Practice. CEIPC 2008 Spanish Adaptation]

The present CEIPC Spanish adaptation of the European Guidelines on Cardiovascular Disease Prevention in Clinical Practice 2008. This guide recommends the SCORE model for risk evaluation. The aim is to prevent premature mortality and morbidity due to CVD by means of dealing with its related risk factors in clinical practice. The guide focuses on primary prevention and emphasizes the role of the nurses and primary care doctors in promoting a healthy life style, based on increasing physical activity, changing dietary habits, and not smoking. The therapeutic goal is to achieve a Blood Pressure<140/90mmHg, but in patients with diabetes, chronic kidney disease, or definite CVD, the objective is<130/80mmHg. Serum cholesterol should be<200mg/dl and cLDL<130mg/dl, although in patients with CVD or diabetes, the objective is<100mg/dl (80mg/dl if feasible in very high-risk patients). Patients with type 2 diabetes and those with metabolic syndrome must lose weight and increase their physical activity, and drugs must be administered whenever applicable, with the objective guided by body mass index and waist circumference. In diabetic type 2 patients, the objective is glycated haemoglobin<7%. Allowing people to know the guides and developing implementation programs, identifying barriers and seeking solutions for them, are priorities for the CEIPC in order to put the recommendations into practice.

Evaluation of Coronary Risk Score Applications in 10-Year Coronary Heart Risk Estimation

Atherosclerosis is a multifactorial disease with risk factors that have multiple effects. In the identification and treatment of asymptomatic individuals at high risk for developing coronary heart disease (CHD) different risk scoring schemes are used in everyday routine. The aim of this study was to compare SCORE recommended for our country with two other most frequently used risk schemes for 10-year CHD risk evaluation: Framingham and PROCAM as well as their modifications. From 220 examined subjects of both sexes, who were treated mainly for lipid metabolism disorder at the Dispensary for Atherosclerosis Prevention, Centre for Laboratory Medicine, Clinical Centre of Vojvodina, 110 subjects were included in our study and agreed to a one-year follow-up. At first check-up, 15% had low risk according to Framingham Weibull and 78% according to PROCAM, intermediate 12% according to PROCAM NS up to 45% according to Framingham Weibull, and high 8% according to PROCAM up to 40% according to Framingham Weibull. After a one-year treatment 30% were in the low risk category according to Framingham Weibull and 88% according to PROCAM. Intermediate from 10% according to PROCAM to 36% according to Framingham Weibull, and high from 2% according to PROCAM to 25% according to Framingham Weibull. There is a significantly lower percentage of high risk individuals and a higher percentage of low risk individuals after one year of lipid disorder treatment.

Ten-Year Survival in 75-Year-Old Men and Women: Predictive Ability of Total Cholesterol, HDL-C, and LDL-C

Objective. The purpose of this study was to investigate prognostic impact of cholesterol and its subfractions among 75-year-old people from the general population. Methods and Results. The study comprised a random sample (222 women and 210 men) from the general population (participation rate 70%). During 10-year follow-up, 19% of women and 35% of men experienced a major cardiovascular event (MCVE). The all-cause mortality was 29% for women and 47% for men. After adjustment for cardiovascular risk factors, a low level of high-density lipoprotein cholesterol (HDL-C) was significantly associated with MCVE (P = .006) and mortality (P = .011) in men but not in women. The prognostic sex disparity was nearly significant (P = .051 for MCVE and .067 for mortality). The associations of adjusted HDL-C to MCVE and mortality were unchanged after excluding individuals with prevalent stroke or MI. Total cholesterol and low-density lipoprotein cholesterol (LDL-C) were not significantly related to prognosis in either sex. Main Conclusions. HDL-C was associated with dismal prognosis in men but not in women. Elderly men with HDL-C <40 mg/dL deserve particular attention for cardiovascular prevention.

Secondary prevention of diabetic patients with coronary artery disease in cardiac rehabilitation: risk factors, treatment and target level attainment

INTRODUCTION

Diabetic patients who have suffered from an acute coronary syndrome (ACS) or have had coronary artery bypass graft (CABG) surgery are at very high risk of recurrent cardiovascular events. Their prognosis, however, can be improved if the target values for blood pressure (BP < 130/80 mmHg) or low density lipoprotein cholesterol [LDL-C < 2.6 mmol/L (100 mg/dl), optionally < 1.8 mmol/L (70 mg/dl)] are achieved. It is not known what proportion of diabetic patients receives such stringent secondary prevention measures and achieves target level attainment for BP, lipids and glucose in cardiac rehabilitation (CR).

METHODS

During 2003 to 2005, 11 973 diabetic (29.7%) and 28 370 non-diabetic patients (70.3%), predominantly after ACS (74 and 80%), were included in a nationwide registry. At entry and at discharge, patient characteristics, pharmacotherapy and blood pressure, lipids and blood glucose were recorded. In a mixed model approach, temporal changes between centres and within centres, respectively, were analysed.

RESULTS

At discharge, a lower proportion of diabetic patients achieved normalisation of BP (in 2005: <140/90 mmHg: 78.4 vs. 82.9% in non-diabetic patients, p < 0.001) or <130/80 mmHg (45.5 vs. 49.8%), respectively. LDL-C < 2.6 mmol/L was more frequently attained in diabetic patients (68.2 vs. 66.5%), as was LDL-C < 1.8 mmol/L (28.8 vs. 23.0%). Fasting blood glucose was not changed during the observation period, as at discharge almost a quarter of all diabetic patients exceeded the threshold value of 7.0 mmol/L (126 mg/dl). In 2005 at discharge, statin therapy was administered in 93% in both diabetics and non-diabetics, acetylic salicylic acid in 79% in diabetics vs. 80% in non-diabetic patients (clopidogrel: 41 vs. 45%).

CONCLUSION

Generally there is room for improvement in the management of cardiac risk factors for both patients groups. In diabetic patients in CR at high risk for recurrent cardiac events, in recent years an improvement of the lipid profile has been observed. Hypertension and glycaemia are still not optimally addressed.

Cardiovascular prevention guidelines in daily practice: a comparison of EUROASPIRE I, II, and III surveys in eight European countries

BACKGROUND

The first and second EUROASPIRE surveys showed high rates of modifiable cardiovascular risk factors in patients with coronary heart disease. The third EUROASPIRE survey was done in 2006-07 in 22 countries to see whether preventive cardiology had improved and if the Joint European Societies' recommendations on cardiovascular disease prevention are being followed in clinical practice.

METHODS

EUROASPIRE I, II, and III were designed as cross-sectional studies and included the same selected geographical areas and hospitals in the Czech Republic, Finland, France, Germany, Hungary, Italy, the Netherlands, and Slovenia. Consecutive patients (men and women </=70 years) were identified after coronary artery bypass graft or percutaneous coronary intervention, or a hospital admission with acute myocardial infarction or ischaemia, and were interviewed at least 6 months later.

FINDINGS

3180 patients were interviewed in the first survey, 2975 in the second, and 2392 in the third. Overall, the proportion of patients who smoke has remained nearly the same (20.3% in EUROASPIRE I, 21.2% in II, and 18.2% in III; comparison of all surveys p=0.64), but the proportion of women smokers aged less than 50 years has increased. The frequency of obesity (body-mass index >/=30 kg/m(2)) increased from 25.0% in EUROASPIRE I, to 32.6% in II, and 38.0% in III (p=0.0006). The proportion of patients with raised blood pressure (>/=140/90 mm Hg in patients without diabetes or >/=130/80 mm Hg in patients with diabetes) was similar (58.1% in EUROASPIRE I, 58.3% in II, and 60.9% in III; p=0.49), whereas the proportion with raised total cholesterol (>/=4.5 mmol/L) decreased, from 94.5% in EUROASPIRE I to 76.7% in II, and 46.2% in III (p<0.0001). The frequency of self-reported diabetes mellitus increased, from 17.4%, to 20.1%, and 28.0% (p=0.004).

INTERPRETATION

These time trends show a compelling need for more effective lifestyle management of patients with coronary heart disease. Despite a substantial increase in antihypertensive and lipid-lowering drugs, blood pressure management remained unchanged, and almost half of all patients remain above the recommended lipid targets. To salvage the acutely ischaemic myocardium without addressing the underlying causes of the disease is futile; we need to invest in prevention.

Efficacy over time of a short overall atherosclerosis management programme on the reduction of cardiovascular risk in patients after an acute coronary syndrome

INTRODUCTION

The prognostic significance of monitoring risk factors and adjusting treatments in patients after an acute coronary syndrome (ACS) is well documented. However, studies over the last few years show that secondary prevention objectives are rarely met. Prevention programmes are effective but their benefit is only partially maintained in long-term follow-up.

AIM OF THE STUDY

To evaluate the efficacy of a global management programme for atherosclerosis (the CEPTA programme) on the long-term monitoring of cardiovascular risk factors, on adherence to treatment, and to compare the data of clinical events post-ACS with that contained in the scientific literature.

PATIENTS AND METHODS

Six hundred and sixty consecutive patients were hospitalised three months after the occurrence of an ACS to evaluate residual risk factors, the atherosclerosis burden, and to undergo a treatment adjustment and a therapeutic and dietary education programme. We evaluated the impact of this long-term programme on the balance of risk factors, treatment maintenance and clinical events. At the end of an average follow-up of 20 months, 96.3% of patients were on antiaggregates, 86.0% were on beta-blockers or Verapamil, 62.4% were on angiotensin-converting enzyme inhibitors or angiotensin to receptor antagonists, 88.4% were on cholesterol-lowering medication and 75.5% were receiving a combination of beta-blocker antiaggregates and cholesterol-lowering drugs. Monitoring of LDL cholesterol and blood pressure was done in over 81 and 71% of patients, respectively. At 20 months of follow-up, total mortality was 3.6% and one cardiovascular event occurred in 12% of patients. In conclusion, this short programme following ACS is beneficial for the long-term management of cardiovascular risk factors and the sustainability of drug treatments.

Assessment of lipid-lowering treatment in France--the CEPHEUS study

OBJECTIVE

Most evidence-based practice guidelines identify low-density lipoprotein cholesterol (LDL-C) as the primary target of cholesterol-lowering therapy; the optimal LDL-C concentration is based on the patient's individual risk level. The aim of this study was to determine the proportion of patients on lipid-lowering drugs who reach the LDL-C goals recommended in guidelines.

METHODS

The CEPHEUS study was conducted in eight European countries in patients, who had been treated with lipid-lowering drugs for at least three months, with no dose adjustment for a minimum of six weeks. In France, throughout 2006, 560 general practitioners enrolled 2222 patients into the study, 1966 of whom gave a fasting blood sample. Lipid and glucose parameters were measured centrally.

RESULTS

Patients had been on treatment for a mean of 5.5+/-5.7 years. Most patients (90.4%) received a single lipid-lowering drug; 84.9% were treated with statins, and the second most frequently used lipid-lowering drugs were fibrates (13.7%). Among the treated subjects, 50% had LDL-C values>3.0 mmol/L, 30% had triglyceride values>1.7 mmol/L and 10% had HDL cholesterol values<1.1 mmol/L. In high-risk patients, as defined by French guidelines, over 55% were above the recommended goal of 2.6 mmol/L. In the subgroup of high-risk patients who did not reach the goals, the LDL-C values were 0.7-1.4 mmol/L over the recommended concentration.

CONCLUSION

The results of this survey highlight the suboptimal management of hypercholesterolaemia in France, particularly in the high-risk population, in whom the percentage who achieved the LDL-C goals was the lowest.

Nine-year trends in achievement of risk factor goals in the US and European outpatients with cardiovascular disease

BACKGROUND

Although control of major cardiovascular risk factors (hypertension, hyperlipidemia, diabetes) has been the centerpiece of guidelines for the prevention of cardiovascular disease, periodic surveys suggest adherence to recommendations and achievement of goals is poor. Few data are available in outpatients, and no studies describe trends in meeting clinical targets.

METHODS

A survey of outpatients with cardiovascular disease or risk factors was conducted annually, with a unique cohort each year, and included medical history, clinical data, and pharmacologic therapies. Data from 1998 to 2006 in the United States, United Kingdom, France, Italy, Spain, and Germany were analyzed for achievement of evidenced-based goals for hypertension, hyperlipidemia, and diabetes.

RESULTS

Over 9 years, 102,318 patients were entered, with a mean age of 60 years, half were male, and each had at least one cardiovascular disease risk factor. In 1998, nearly half of patients in the United States were not at their target for blood pressure or low-density lipoprotein cholesterol. In Europe, <1 in 3 was at blood pressure goal, and a minority had low-density lipoprotein recorded. Only modest improvements were observed by 2006. Hemoglobin A(1c) levels improved from 2005 to 2006 in the United States and Europe, indicating improving glycemic control in these cohorts.

CONCLUSIONS

Adherence to guidelines in these outpatients was suboptimal and lower in Europe than in the United States. Increased adherence to evidence-based targets for the treatment of hypertension, hyperlipidemia, and diabetes is needed to achieve ideal cardiovascular prevention.

Detection of Cytomegalovirus in Atherosclerotic Plaques and Nonatherosclerotic Arteries

Several studies have reported an association between infectious agents and atherosclerosis. Cytomegalovirus (CMV) is the most commonly implicated viral pathogen. However, the role of CMV in atherosclerosis remains obscure. The present study evaluated the presence of CMV DNA in atherosclerotic plaques and normal vessel walls. A total of 40 arterial specimens from coronary plaques and 27 samples from normal vessels were obtained from 26 patients who underwent aortocoronary bypass surgery. The specimens were analyzed by polymerase chain reaction for the presence of the CMV immediate early genomic region. CMV DNA was detected in 9 out of 26 patients (34.6%). Viral DNA was detected in both nonatherosclerotic tissues and atherosclerotic plaques. No statistically significant differences were observed between normal and diseased vessels. Our findings, in accordance with previous studies, do not support a direct causative role of CMV in the development of atherosclerotic plaques.

Three life-years gained from smoking cessation after coronary artery bypass surgery: a 30-year follow-up study

BACKGROUND

Previous studies have shown that smoking cessation after a cardiac event reduces the risk of subsequent mortality in patients, but the effect of smoking cessation in terms of prolonged life-years is not yet known.

METHODS

We analyzed the 30-year clinical outcome of the first 1,041 consecutive patients (age at operation 51 years, 92% male) who successfully underwent isolated venous coronary artery bypass surgery between 1971 and 1980. All 551 smokers (53%) were included in this study. Of these, 43% stopped smoking throughout the first year whereas 57% persisted smoking.

RESULTS

The median follow-up was 29 years (range 26-36 years). The cumulative 10-, 20-, and 30-year survival rates were 88%, 49%, and 19%, respectively, in the group of patients who quit smoking, and only 77%, 36%, and 11%, respectively, in the persistent smokers (P < .0001). After adjusting for all baseline characteristics, smoking cessation remained an independent predictor of lower mortality (hazard ratio 0.60, 95% CI 0.48-0.72). We were able to assess the exact life expectancy by calculating the area under the Kaplan-Meier curves. Life expectancy in the quitters was 20.0 years and 17.0 years in the persistent smokers (P < .0001).

CONCLUSIONS

Using 30-year follow-up data, we estimated that self-reported smoking cessation after coronary artery bypass surgery was associated with a life expectancy gain of 3 years. Smoking cessation turned out to have a greater effect on reducing the risk of mortality than the effect of any other intervention or treatment.

Treatment potential for cholesterol management in patients with coronary heart disease in 15 European countries: Findings from the EUROASPIRE II survey

BACKGROUND

During the last decade, the evidence of beneficial effects of cholesterol lowering in patients with coronary heart disease (CHD) has been proven in several clinical trials. This has prompted international guidelines on prevention of CHD to include recommendations on dietary and pharmacological treatment of hyperlipidaemia with set goals on total- and LDL-cholesterol.

METHODS

The first EUROASPIRE survey performed in 1995/1996 showed poor adherence to the European recommendations on lipid-lowering in patients with CHD. The second survey was carried out in 1999/2000 in 15 European countries and enrolled 8181 patients with CHD. Medical records were assessed and clinical examinations of risk factors including serum lipids were performed. The aim of this survey is to describe the treatment of hyperlipidaemia among CHD patients in Europe.

RESULTS

The proportion of patients not reaching the target of 5.0mmol/l was 58.3% with significant variations between countries. The use of lipid-lowering drugs was relatively high (60.9%). However, the most frequently used doses of lipid-lowering agents were much lower than the doses of proven effect used in clinical trials.

CONCLUSIONS

Although the treatment of hyperlipidaemia in CHD patients seems to be improving as compared to the first survey, a significant number of patients do not reach treatment goals. If the full potential of lipid-lowering therapy was utilised with all eligible patients treated and doses titrated correctly, more patients would benefit in terms of reduced morbidity and mortality of CHD.

Cost-effectiveness of rosuvastatin in the prevention of ischemic heart disease in Portugal

OBJECTIVE

To assess the cost-effectiveness of rosuvastatin in the treatment of hypercholesterolemia and the prevention of ischemic heart disease (IHD) in Portugal.

METHODS

A probabilistic Markov model was constructed to analyze the costs and consequences of lifetime treatment with rosuvastatin, atorvastatin, pravastatin, and simvastatin. For this purpose, the results from randomized head-to-head trials evaluating low-density lipoprotein (LDL) changes were combined with the results from a meta-analysis defining the relationship between LDL levels and fatal and nonfatal IHD events. The incidence of myocardial infarction (MI) was derived from a 9-year Portuguese observational study. The eligible population was defined as untreated individuals aged more than 35 years with LDL levels above 115 mg/dl. Death rates due to IHD and other causes were obtained from official data. Resource use in the treatment of MI was estimated by a Delphi panel of eight Portuguese cardiologists with at least 15 years of clinical practice. Costs were calculated from the payers' perspective.

RESULTS

Rosuvastatin increases life expectancy between 5.5 and 12.1 days per patient. It is cost-saving when compared to atorvastatin, but it increases costs when assessed against pravastatin and simvastatin (euro1,004 and euro684 per patient, respectively). Therefore, rosuvastatin is a dominant alternative compared to atorvastatin, having an incremental cost-effectiveness ratio of euro30,350 to pravastatin and euro39,340 to simvastatin. In the probabilistic sensitivity analysis, performed rosuvastatin always dominates atorvastatin and is associated with a cost per life-year gained inferior to euro50,000 in 95.7% of the cases when compared to pravastatin and in 67.0% simulations when assessed against simvastatin.

CONCLUSIONS

Rosuvastatin is a cost-effective alternative in the prevention of IHD in Portugal.

Cholesterol goal attainment in patients with coronary heart disease and elevated coronary risk: results of the Hong Kong hospital audit study

OBJECTIVE

We sought to determine 1) long-term lipid-lowering treatment patterns; 2) cholesterol goal attainment rates and possible determinants of goal achievement; and 3) effects of cholesterol goal attainment on coronary events in hospitalized Hong Kong patients.

METHODS

In this retrospective cohort analysis, records of two public Hong Kong hospitals were reviewed for 196 adults (69% with coronary heart disease (CHD) or CHD-risk equivalent) who received at least one lipid-lowering therapy during hospitalization. Low-density lipoprotein cholesterol (LDL-C) targets were <2.6 mmol/l (<100 mg/dL) for patients with CHD or CHD risk equivalents and <3.37 mmol/l (<130 mg/dL) for those without.

RESULTS

Most participants were initiated on regimens of low to midequipotency doses and never had their regimens adjusted to higher potency. Approximately 44% of patients not at LDL-C at baseline failed to achieve goal during a median follow-up of 1.9 years. Patients with higher coronary risk and/or LDL-C levels at baseline were less likely than their lower-risk counterparts to achieve goal; for each 1-mmol/l (38.7-mg/dL) increase in LDL-C at baseline, the likelihood of attaining goal declined by 64%. Patients achieving cholesterol goal had significantly longer cardiovascular event-free times.

CONCLUSIONS

A total of 44% of Hong Kong patients not at LDL-C goals at baseline did not achieve them over 1.9 years. More effective and well-tolerated therapies, including adjunctive regimens (e.g., ezetimibe-statin, niacin-statin), may be necessary to enhance LDL-C goal achievement and increase event-free time.

Monitoring treatment fidelity in a randomized controlled trial of a complex intervention

AIM

This paper is a report of a study to describe how treatment fidelity is being enhanced and monitored, using a model from the National Institutes of Health Behavior Change Consortium.

BACKGROUND

The objective of treatment fidelity is to minimize errors in interpreting research trial outcomes, and to ascribe those outcomes directly to the intervention at hand. Treatment fidelity procedures are included in trials of complex interventions to account for inferences made from study outcomes. Monitoring treatment fidelity can help improve study design, maximize reliability of results, increase statistical power, determine whether theory-based interventions are responsible for observed changes, and inform the research dissemination process.

METHODS

Treatment fidelity recommendations from the Behavior Change Consortium were applied to the SPHERE study (Secondary Prevention of Heart DiseasE in GeneRal PracticE), a randomized controlled trial of a complex intervention. Procedures to enhance and monitor intervention implementation included standardizing training sessions, observing intervention consultations, structuring patient recall systems, and using written practice and patient care plans. The research nurse plays an important role in monitoring intervention implementation.

FINDINGS

Several methods of applying treatment fidelity procedures to monitoring interventions are possible. The procedure used may be determined by availability of appropriate personnel, fiscal constraints, or time limits. Complex interventions are not straightforward and necessitate a monitoring process at trial stage.

CONCLUSION

The Behavior Change Consortium's model of treatment fidelity is useful for structuring a system to monitor the implementation of a complex intervention, and helps to increase the reliability and validity of evaluation findings.

Aspirin use for the primary prevention of coronary heart disease: a population-based study in Switzerland

OBJECTIVE

To determine the patterns of aspirin use for the primary prevention of coronary heart disease (CHD). Aspirin for primary prevention has a more favorable risk/benefit profile among adults with high CHD risk than among low-risk adults.

METHOD

We studied 5725 adults aged 35-75 without cardiovascular disease in a population-based study in Switzerland in 2003-2006. We examined regular aspirin use for cardiovascular prevention according to 10-year CHD risk and other cardiovascular risk factors.

RESULTS

One hundred seventy-four participants used aspirin. Aspirin use increased with 10-year CHD risk, from 2.6% in persons with risk <6% (low risk) to 9% in those with risk 6-20% (intermediate risk, p=0.001), but no adults with risk >or=20% used aspirin. Participants with cardiovascular risk factors were more likely to use aspirin. However, 1.9% adults with risk <6% and no diabetes used aspirin. Using a population perspective, a more appropriate aspirin use would reduce up to 2,348/24,310 CHD deaths expected over 10 years in Switzerland, and avoid about 700 gastrointestinal bleedings and hemorrhagic strokes among those not eligible.

CONCLUSION

Individuals at intermediate CHD risk and diabetics are more likely to take aspirin, but there are significant opportunities for improvement. The underuse of aspirin for those at risk coexists with an overuse among those at low risk.

Mixed dyslipidemia among patients using lipid-lowering therapy in French general practice: an observational study

BACKGROUND

Low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglycerides (TGs) are associated with an increased incidence of coronary heart disease (CHD). However, limited data are available about the prevalence of dyslipidemias related to LDL-C, HDL-C, and TGs among French patients treated with lipid-lowering agents.

OBJECTIVE

This paper describes the prevalence of various types of dyslipidemias among patients treated with lipid-lowering agents in French general practice.

METHODS

This was a cross-sectional, observational study conducted using retrospective data collection at the time of enrollment. Eligible patients were those treated pharmacologically for dyslipidemia in the Cegedim Strategic Data general practice network. Fasting lipid values and cardiovascular (CV) risk factors were gathered by investigators using an ad hoc questionnaire. European guidelines were used to define various types of dyslipidemias. Polytomous logistic regression was used to assess the associations between different dyslipidemias and diabetes mellitus, a history of CHD, and the number of CV risk factors.

RESULTS

A total of 946 patients had a complete lipid profile and valid data for determining CV risk status. The mean (SD) age of these patients was 64.0 (9.9) years, and 55.7% of the patients were men. At least 1 abnormality in LDL-C, HDL-C, or TGs was present in 791 (83.6 %) of the 946 patients. The rates of elevated LDL-C, low HDL-C, and elevated TGs were 73.2%, 16.9%, and 30.3%, respectively (these groups are not mutually exclusive). Among those who did not reach the LDL-C goal, 38.7% had dyslipidemias with low HDL-C, elevated TGs, or both. Compared with having a normal lipid profile, each additional CV risk factor increased the likelihood of the following types of dyslipidemias: low HDL-C and/or elevated TGs, but normal LDL-C (odds ratio [OR], 1.36; 95% CI, 1.03-1.79); elevated LDL-C and TGs, but normal HDL-C (OR, 1.58; 95% CI, 1.24-2.02); and all 3 lipid abnormalities (OR, 1.54; 95% CI, 1.10-2.14). Patients with diabetes had a similarly increased risk of mixed dyslipidemias, whereas patients with a history of CHD did not.

CONCLUSIONS

Among these patients treated with lipid-lowering agents, 38.7% had mixed dyslipidemias, including low HDL-C, elevated TGs, both low HDL-C and elevated TGs, or all 3 lipid abnormalities. Patients with a greater number of nonlipid CV risk factors or with diabetes had a significantly increased risk of mixed dyslipidemias involving elevated TGs and/or low HDL-C in addition to elevated LDL-C.

Heart rate recovery is more strongly associated with the metabolic syndrome, waist circumference, and insulin sensitivity in women than in men among the elderly in the general population

BACKGROUND

Low heart rate recovery (HRR) at exercise test and the metabolic syndrome (MetS) are both predictors of cardiovascular morbidity and mortality. We studied in 75-year-old women and men, representative of the general population, the relationship between (1) HRR and the MetS, (2) HRR and the individual components of the MetS, and (3) HRR and insulin sensitivity.

METHODS

A cross-sectional study of randomly selected 75-year-olds from a general population was performed (191 women and 194 men). The MetS was defined according to the National Cholesterol Education Program criteria. Heart rate was measured as beats per minute immediately after exercise and at 4 minutes into recovery.

RESULTS

Heart rate recovery (median and interquartile range, beat/min) was 48 (37-58) for women and 49 (38-58) for men. Thirty-seven percent of the women and 25% of the men had the MetS. Heart rate recovery was 52 (42-61) for women with the MetS and 42 (31-49) for those without. The corresponding values for men was 50 (39-61) and 47 (35-54); the difference between individuals with and without the MetS was significant for women (P < .001) but not for men (P = .084). The following significant correlation coefficients between HRR and MetS components were found: for women, waist circumference (-0.43, P < .001), high-density lipoprotein cholesterol (0.37, P < .001), insulin sensitivity (-0.37, P < .001), fasting plasma glucose (-0.30, P < .001), and triglycerides (-0.24, P = .001); for men, triglycerides (-0.20, P = .005). The sex disparity in the strength of correlation reached statistical significance for insulin sensitivity (P < .001) and waist circumference (P = .042).

CONCLUSION

Among 75-year-olds, the MetS and related components are more strongly correlated to HRR in women than in men.

Resting heart rate in cardiovascular disease

The importance of resting heart rate (HR) as a prognostic factor and potential therapeutic target is not yet generally accepted. Recent large epidemiologic studies have confirmed earlier studies that showed resting HR to be an independent predictor of cardiovascular and all-cause mortality in men and women with and without diagnosed cardiovascular disease. Clinical trial data suggest that HR reduction itself is an important mechanism of benefit of beta-blockers and other heart-rate lowering drugs used after acute myocardial infarction, in chronic heart failure, and in stable angina pectoris. Pathophysiological studies indicate that a relatively high HR has direct detrimental effects on the progression of coronary atherosclerosis, on the occurrence of myocardial ischemia and ventricular arrhythmias, and on left ventricular function. Studies have found a continuous increase in risk with HR above 60 beats/min. Although it may be difficult to define an optimal HR for a given individual, it seems desirable to maintain resting HR substantially below the traditionally defined tachycardia threshold of 90 or 100 beats/min. These findings suggest that the potential role of HR and its modulation should be considered in future cardiovascular guidance documents.

Total cardiovascular risk management

Hypertension usually clusters with other cardiovascular risk factors, such as insulin resistance, visceral obesity, and dyslipidemia, greatly increasing an individual's risk for cardiovascular morbidity and death. Despite universal recognition that reduction in blood pressure and other cardiovascular risk factors is essential to improving long-term cardiovascular health, <25% of patients diagnosed with hypertension have adequate blood pressure control. Total cardiovascular risk is increased in the presence of risk factors, target organ damage, comorbid conditions, and the metabolic syndrome and may, to some extent, be prenatally determined. Individuals with "borderline" normal blood pressure and blood glucose are also at increased risk for cardiovascular disease, giving rise to the concept of individuals with "prehypertension" and "prediabetes." International treatment guidelines are now incorporating the concept of global cardiovascular risk assessment and management to improve long-term outcomes. Multifactorial intervention has proved to be highly effective at reducing cardiovascular risk and events in patients with type 2 diabetes mellitus, and studies suggest that reducing an array of risk factors by relatively small amounts can be more beneficial than achieving large reductions in a single risk factor. Clearly, isolated treatment of hypertension is no longer sufficient; risk factors and target organ damage need to be actively searched for and treated if long-term cardiovascular health is to be improved.

Measurement of coronary calcium scores or exercise testing as initial screening tool in asymptomatic subjects with ST-T changes on the resting ECG: an evaluation study

BACKGROUND

Asymptomatic subjects at intermediate coronary risk may need diagnostic testing for risk stratification. Both measurement of coronary calcium scores and exercise testing are well established tests for this purpose. However, it is not clear which test should be preferred as initial diagnostic test. We evaluated the prevalence of documented coronary artery disease (CAD) according to calcium scores and exercise test results.

METHODS

Asymptomatic subjects with ST-T changes on a rest ECG were selected from the population based PREVEND cohort study and underwent measurement of calcium scores by electron beam tomography and exercise testing. With calcium scores > or =10 or a positive exercise test, myocardial perfusion imaging (MPS) or coronary angiography (CAG) was recommended. The primary endpoint was documented obstructive CAD (>/=50% stenosis).

RESULTS

Of 153 subjects included, 149 subjects completed the study protocol. Calcium scores > or =400, 100-399, 10-99 and <10 were found in 16, 29, 18 and 86 subjects and the primary endpoint was present in 11 (69%), 12 (41%), 0 (0%) and 1 (1%) subjects, respectively. A positive, nondiagnostic and negative exercise test was present in 33, 27 and 89 subjects and the primary endpoint was present in 13 (39%), 5 (19%) and 6 (7%) subjects, respectively. Receiver operator characteristics analysis showed that the area under the curve, as measure of diagnostic yield, of 0.91 (95% CI 0.84-0.97) for calcium scores was superior to 0.74 (95% CI 0.64-0.83) for exercise testing (p = 0.004).

CONCLUSION

Measurement of coronary calcium scores is an appropriate initial non-invasive test in asymptomatic subjects at increased coronary risk.

A global survey of physicians' perceptions on cholesterol management: the From The Heart study

AIMS

Guidelines for cardiovascular disease (CVD) prevention cite high levels of low-density lipoprotein cholesterol (LDL-C) as a major risk factor and recommend LDL-C goals for various risk groups. Lifestyle changes are advised as first-line treatment for patients with high cholesterol, and statins are recommended in high-risk patients. The From The Heart study investigated current practice for the diagnosis and treatment of high cholesterol, and attitudes towards management of the condition.

METHODS

Physicians were randomly selected from 10 countries, and completed a confidential, semi-structured questionnaire.

RESULTS

Of 2790 physicians agreeing to participate, 750 (27%) responded. Physicians rated CVD as the leading cause of death, although physicians (80%) perceived that cancer was the most feared illness among patients. Physicians (71%) believed smoking to be the greatest CVD risk factor, while only 50% thought high cholesterol was the greatest risk. Most physicians (81%) used guidelines to set cholesterol goals, primarily their national guidelines (34%) or the National Cholesterol Education Program Adult Treatment Panel III guidelines (24%). Although only 47% of patients reached and maintained their cholesterol goals, 61% of physicians believed that a sufficient number of patients achieved goals, and 53% did not feel frustrated that they could not always effectively treat patients with CVD.

CONCLUSION

Results indicate discrepancies between guideline recommendations and clinical practice. Although physicians appreciate the risk of CVD, the importance of achieving healthy cholesterol levels for CVD prevention does not seem to be widely endorsed. There is a need for improved communication regarding the importance of cholesterol lowering and investigation of initiatives to improve goal achievement among physicians.

Validity of the Framingham point scores in the elderly: results from the Rotterdam study

BACKGROUND

The National Cholesterol Education Program recommends assessing 10-year risk of coronary heart disease (CHD) in individuals free of established CHD with the Framingham Point Scores (FPS). Individuals with a risk >20% are classified as high risk and are candidates for preventive intervention. We aimed to validate the FPS in a European population of elderly subjects.

METHODS

Subjects free of established CHD at baseline were selected from the Rotterdam study, a population-based cohort of subjects 55 years or older in The Netherlands. We studied calibration, discrimination (c-index), and the accuracy of high-risk classifications. Events consisted of fatal CHD and nonfatal myocardial infarction.

RESULTS

Among 6795 subjects, 463 died because of CHD and 336 had nonfatal myocardial infarction. Predicted 10-year risk of CHD was on average well calibrated for women (9.9% observed vs 10.1% predicted) but showed substantial overestimation in men (14.3% observed vs 19.8% predicted), particularly with increasing age. This resulted in substantial number of false-positive classifications (specificity 70%) in men. In women, discrimination of the FPS was better than that in men (c-index 0.73 vs 0.63, respectively). However, because of the low baseline risk of CHD and limited discriminatory power, only 33% of all CHD events occurred in women classified as high risk.

CONCLUSIONS

The FPS need recalibration for elderly men with better incorporation of the effect of age. In elderly women, FPS perform reasonably well. However, maintaining the rational of the high-risk threshold requires better performing models for a population with low incidence of CHD.

Prediction of first coronary events with the Framingham score: a systematic review

BACKGROUND

Uncertainty exists about the performance of the Framingham risk score when applied in different populations.

OBJECTIVE

We assessed calibration of the Framingham risk score (ie, relationship between predicted and observed coronary event rates) in US and non-US populations free of cardiovascular disease.

METHODS

We reviewed studies that evaluated the performance of the Framingham risk score to predict first coronary events in a validation cohort, as identified by Medline, EMBASE, BIOSIS, and Cochrane library searches (through August 2005). Two reviewers independently assessed 1496 studies for eligibility, extracted data, and performed quality assessment using predefined forms.

RESULTS

We included 25 validation cohorts of different population groups (n = 128,000) in our main analysis. Calibration varied over a wide range from under- to overprediction of absolute risk by factors of 0.57 to 2.7. Risk prediction for 7 cohorts (n = 18658) from the United States, Australia, and New Zealand was well calibrated (corresponding figures: 0.87-1.08; for the 5 biggest cohorts). The estimated population risks for first coronary events were strongly associated (goodness of fit: R2 = 0.84) and in good agreement with observed risks (coefficient for predicted risk: beta = 0.84; 95% CI 0.41-1.26). In 18 European cohorts (n = 109499), the corresponding figures indicated close association (R2 = 0.72) but substantial overprediction (beta = 0.58, 95% CI 0.39-0.77). The risk score was well calibrated on the intercept for both population clusters.

CONCLUSION

The Framingham score is well calibrated to predict first coronary events in populations from the United States, Australia, and New Zealand. Overestimation of absolute risk in European cohorts requires recalibration procedures.

Diabetes Care for Patients with Peripheral Arterial Disease

The number of diabetics will increase almost 70% in developed countries during the next 20 years: peripheral arterial disease is a common and costly complication. The incidence of cardiovascular disease (mortality and morbidity) due to atherosclerosis, is higher among patients with diabetes than in those without diabetes. Intensive management of diabetes, including glycaemic control, treatment of hypertension and dyslipidemia, as well as nonpharmacological interventions, decreases both micro- and macrovascular complications. Aspirin and clopidogrel have less antiplatelet effect in patients with diabetes. Metformin therapy is considered a risk factor for lactic acidosis if not withdrawn 2 days before angiography, but this risk is extremely low in patients with normal renal function. Peri-operative hyperglycaemia and large fluctuations in plasma glucose increase postoperative mortality and morbidity and careful measures are required to minimise these effects.

Higher prevalence of smoking and lower BMI, waist circumference, cholesterol and triacylglyceride levels in Prague's homeless compared to a majority of the Czech population

Background

Homeless people have higher morbidity and mortality rates than the general population. Research has shown that cardiovascular disease is the leading cause of death in older homeless adults. This study was undertaken to describe the prevalence of cardiovascular risk factors in the homeless population in Prague.

Methods

Data was obtained from a cross-sectional study carried out in 2003. Body mass index (BMI), waist circumference (WC), total cholesterol (TC), triacylglycerides (TAG) and smoking habits were assessed. The homeless participants in the study were recruited from a homeless center run by a Prague charitable organization called Naděje ("Hope") and at Prague's main railway station. Most participants were assessed at the Naděje center (134 persons) while the rest were assessed at Prague's Bulovka University Hospital (67 persons).

Results

A total of 201 homeless (174 males and 27 females) aged 19 – 70 years were examined. Mean values of BMI, WC, TC and TAG in homeless men and women were within normal limits. Compared with the majority of the Czech population, the homeless had significantly lower mean levels of TC and TAG and lower BMI and WC values. When compared to the majority of the Czech population, the incidence of smoking among the homeless was significantly higher. Among smokers in both populations, no differences were found in the number of cigarettes smoked per day.

Conclusion

Classical cardiovascular risk factors such as TC, TAG, BMI and WC, are significantly lower in Prague's homeless minority than in the majority of the Czech population. However, the prevalence of smoking is much higher in the homeless population.

The importance of total cardiovascular risk assessment in clinical practice

BACKGROUND

The Third Joint European Guidelines on Cardiovascular Disease (CVD) Prevention highlight the importance of total cardiovascular risk prediction in planning preventive strategies.

AIM

To review the development of risk prediction systems in Europe and the practicalities of utilizing risk prediction in everyday clinical practice.

METHODS

Randomised clinical trials, cohort studies and current guidelines for the management of cardiovascular risk were reviewed. Relevant articles published between 1960 and 2004 were identified on PubMed and the Internet.

RESULTS

Several risk factors have been confirmed as major independent predictors of CVD, with their modification reducing cardiovascular risk. Total risk assessment is essential as multiple risk factors confer greater risk than the sum of their components. Framingham Heart Study data have been used as the basis for several risk prediction systems, which have been incorporated into numerous guidelines. However, these data are from a relatively small American cohort and tend to overestimate risk in some European populations. This and other limitations prompted the development of the SCORE (Systematic Coronary Risk Evaluation) risk charts using a much larger dataset from 12 European cohort studies. An electronic version of the charts, HeartScore, is now available to provide practitioners with an interactive risk prediction and management system that can be tailored to individual countries.

CONCLUSION

Evidence-based risk assessment systems can facilitate logical, individually tailored risk management and contribute to better patient care. Secular changes in coronary heart disease (CHD) incidence and mortality as well as in risk factors such as obesity and diabetes mean that such systems should be capable of modification and evolution.