Dyslipidaemias and Cardiovascular Disease: Focus on the Role of PCSK9 Inhibitors

Genetic, experimental and clinical studies have consistently confirmed that inhibition of Proprotein Convertase Subtilisin/Kexin type 9 (PCSK9) can result in significant lowering of LDL-C and two fully human PCSK9 monoclonal antibodies have received regulatory approval for use in highrisk patients. Co-administration of PCSK9 with statins has resulted in extremely low LDL-C levels with excellent short-term safety profiles. While results from Phase III clinical trials provided significant evidence about the role of PCSK9 inhibitors in reducing cardiovascular event rates, their impact on mortality remains less clear. PCSK9 inhibitor therapy can be considered for high-risk patients who are likely to experience significant cardiovascular risk reduction.

Alcohol consumption patterns across Europe and adherence to the European guidelines in coronary patients: Findings from the ESC-EORP EUROASPIRE V survey

BACKGROUND AND AIMS

Alcohol consumption is an important risk factor for cardiovascular morbidity and mortality worldwide. The highest levels of alcohol consumption are observed in Europe, where alcohol as contributing cause of coronary heart disease (CHD) is also most significant. We aimed to describe alcohol consumption patterns across European regions and adherence to the current guidelines in patients with a recent CHD event.

METHODS

The ESC-EORP survey (EUROASPIRE V) has been conducted in 2016-2017 at 131 centers in 27 European countries in 7350 patients with a recent CHD. Median alcohol consumption, as well as the proportion of abstainers and excessive drinkers (i.e. >70 g/week for women and >140 for men, as recommended by the European guidelines on cardiovascular prevention), was calculated for each region. To assess adherence to guidelines, proportions of participants who were advised to reduce excessive alcohol consumption and participants who were incorrectly not advised were calculated per region.

RESULTS

Mean age was 64 years (SD: 9.5), 75% were male. Abstention rates were 53% in males and 77% in females, whereas excessive drinking was reported by 9% and 5% of them, respectively. Overall, 57% of the participants were advised to reduce alcohol consumption. In the total population, 3% were incorrectly not advised, however, this percentage differed per region (range: 1%-9%). In regions where alcohol consumption was highest, participants were less often advised to reduce their consumption.

CONCLUSION

In this EUROASPIRE V survey, the majority of CHD patients adhere to the current drinking guidelines, but substantial heterogeneity exists between European regions.

Nurse-led Motivational Telephone Follow-up After Same-day Percutaneous Coronary Intervention Reduces Readmission and Contacts to General Practice

BACKGROUND

Same-day discharge of patients undergoing percutaneous coronary intervention (PCI) may challenge preparation of patients for discharge.

OBJECTIVE

The objective of this study was to investigate whether nurse-led telephone follow-up influenced patients' self-management post-PCI.

METHODS

We performed a randomized study with an allocation rate of 1:1. A standardized nurse-led motivational telephone consultation was conducted between 2 and 5 days after PCI to support adherence to medical therapy, follow-up activities, emotional well-being, and healthy lifestyle. The control group received usual care and discharge procedures. Primary outcome was adherence to use of P2Y12 inhibitor (clopidogrel or ticagrelor) therapy at 30 days of follow-up.

RESULTS

We consecutively included 294 elective patients (83%) undergoing PCI and with planned same-day discharge. Adherence to P2Y12 inhibitors was not influenced by the intervention (intervention vs control, 95% vs 93%, respectively; P = .627). However, the proportion of patients readmitted (8% vs 16%, P = .048), as well as self-initiated contacts to general practitioners (29% vs 42%, P = .020), was lower in the intervention group compared with the control group. Patients in the intervention group were more likely to know how to manage symptoms of angina pectoris (90% vs 80%, P = .015), and a higher proportion of patients in the intervention group commenced healthy physical activities (53% vs 41%, P = .043).

CONCLUSION

Nurse-led motivational telephone follow-up did not influence adherence to antiplatelet medical therapy after PCI. However, the intervention positively influenced self-management of angina pectoris and reduced hospital readmissions and self-initiated contacts to general practitioners and hospitals.

Association between β-blocker dose and cardiovascular outcomes after myocardial infarction: insights from the SWEDEHEART registry

AIMS

Dose-dependent effects of β-blockers on survival and cardiovascular outcomes after myocardial infarction (MI) are not well understood. We investigated the long-term risk of cardiovascular events in patients with different doses of β-blockers after MI.

METHODS AND RESULTS

This was a nationwide observational study linking morbidity, mortality, socioeconomic, and medication data from Swedish national registries. Between 2006 and 2015, 97 575 unique patients with first-time MI were included. In total, 33 126 (33.9%) patients were discharged with ≥50% of the target β-blocker dose and 64 449 (66.1%) patients with <50% of the target β-blocker dose used in previous randomized trials. The primary composite endpoint was re-infarction or all-cause death within 1 year from discharge. Multivariable adjusted 1-year follow-up estimates using mixed effects Cox regression [HR (95% CI)] showed that patients treated with ≥50% of the target dose had a similar risk of the composite endpoint [1.03 (0.99-1.08)] and a somewhat higher risk when stroke, atrial fibrillation, or heart failure hospitalization were added to the composite endpoint [1.08 (1.04-1.12)], compared with patients on <50% of the target β-blocker dose. Results remained similar up to 5 years of follow-up and consistent across relevant patient subgroups, including patients who developed heart failure during the index hospitalization.

CONCLUSIONS

In contrast to doses of β-blockers used in previous trials, ≥50% of the target β-blocker dose was not associated with superior cardiovascular outcomes up to 5 years as compared with <50% of the target dose. Contemporary randomized clinical trials are needed to clarify the optimal dose of β-blockers after MI.

Nurses' perceptions of patient participation in the myocardial infarction pathway

Aim

To explore nurses' perceptions of patient participation in different phases of the myocardial infarction pathway.

Design

Qualitative design with a hermeneutical approach.

Methods

Five focus groups were conducted at two hospitals, one with and one without percutaneous coronary intervention facilities, between February-November 2018. Participants were recruited through purposive sampling. Twenty-two nurses experienced in cardiac care participated. The analysis had a hermeneutical approach.

Results

The findings revealed nurses' perceptions of patient participation in different phases of the myocardial infarction pathway. Four themes were identified: (a) variation between paternalism and autonomy in the acute phase; (b) individualization of dialogue and patient participation during treatment; (c) lack of coherence in the pathway hinders patient participation at discharge; and (d) cardiac rehabilitation promotes patients' autonomous decisions in lifestyle changes.

"It's up to me": the experience of patients at high risk of cardiovascular disease of lifestyle change

OBJECTIVE

Despite knowledge of the effect of lifestyle changes in preventing cardiovascular disease, a large proportion of people have unhealthy lifestyle habits. The aim of our study is a) to explore the experiences of participants at high risk of CVD of lifestyle change after participation in a one-year structured lifestyle counselling programme and b) to link the techniques and strategies used by the participants to the processes of the transtheoretical model of behaviour change (TTM).

DESIGN

A qualitative explorative design was used to collect data on participants' experiences. An abductive content analysis was conducted using the processes within TTM for the deductive analysis.

SETTING

Patients that participated in a one-year lifestyle counselling programme in Swedish primary care, were interviewed.

SUBJECTS

Eight men and eight women, aged 51-75 years, diagnosed with hypertension or type 2 diabetes mellitus.

MAIN OUTCOME MEASURES

Experiences of lifestyle change in patients at high cardiovascular risk.

RESULTS

The analysis yielded four dimensions that assisted lifestyle change: 'The value of knowledge', 'Taking control', 'Gaining trust in oneself' and 'Living with a chronic condition'. The theme 'It's up to me' illustrated that lifestyle change was a personal matter and responsibility.

CONCLUSION

Enhanced knowledge, self-efficacy, support from others and the individual's insight that it was his/her own decisions and actions that mattered were core factors to adopt healthier lifestyle habits. Practice Implications: Although lifestyle change is a personal matter, the support provided by primary healthcare professionals and significant others is essential to increase self-efficacy and motivate lifestyle change. Key Points A large proportion of people persist to have unhealthy lifestyle habits also after receiving a diagnosis of hypertension or diabetes mellitus, type 2. This study contributes to enhanced knowledge of how patients experience lifestyle change after counselling in primary care. Both experiential and behavioural processes as defined by the transtheoretical model of behaviour change were used to make lifestyle changes by the patients in this study.

Low-Density Lipoprotein Cholesterol Targets in Patients With Coronary Heart Disease in Extremadura (Spain): LYNX Registry

Background

Low-density lipoprotein cholesterol (LDL-C) contributes decisively to the development of cardiovascular disease (CVD). In the LYNX registry we determined the rate of achievement of the target value of LDL-C, the use of lipid-lowering therapy (LLT) and the predictive factors of not reaching the target in patients with stable coronary heart disease (CHD).

Methods

LYNX included consecutive patients with stable CHD treated at the University Hospital of Caceres, Extremadura (Spain) from September 2016 to September 2018, and those who must have an LDL-C target below 70 mg/dL according to the European Society of Cardiology (ESC) 2016 guidelines. The variables independently associated with the breach of the LDL-C objective were evaluated by multivariable logistic regression.

Results

A total of 674 patients with stable CHD were included. The average LDL-C levels were 68.3 ± 24.5 mg/dL, with 56.7% showing a level below 70 mg/dL. LLT was used by 96.7% of patients, 71.7% were treated with high-powered statins and 30.1% with ezetimibe. The risk of not reaching the target value of LDL-C was higher in women, in active smokers, and in those who had multivessel CHD or had atrial fibrillation. Patients with diabetes mellitus, those who took potent statins or co-administration treatment with ezetimibe were more likely to reach the target level of LDL-C.

Conclusions

The treatment of dyslipidemia in patients with chronic CHD remains suboptimal; however, an increasing number of very high-risk patients achieve the LDL-C objective, although there is still enormous potential to improve cardiovascular outcome through the use of more intensive LLT.

Implementing recommendations for inpatient healthcare provider encouragement of cardiac rehabilitation participation: development and evaluation of an online course

BACKGROUND

A policy statement recommending that healthcare providers (HCPs) encourage cardiac patients to enroll in cardiac rehabilitation (CR) was recently endorsed by 23 medical societies. This study describes the development and evaluation of a guideline implementation tool.

METHODS

A stepwise multiple-method study was conducted. Inpatient cardiac HCPs were recruited between September 2018-May 2019 from two academic hospitals in Toronto, Canada. First, HCPs were observed during discharge discussions with patients to determine needs. Results informed selection and development of the tool by the multidisciplinary planning committee, namely an online course. It was pilot-tested with target users through a think-aloud protocol with subsequent semi-structured interviews, until saturation was achieved. Results informed refinement before launching the course. Finally, to evaluate impact, HCPs were surveyed to test whether knowledge, attitudes, self-efficacy and practice changed from before watching the course, through to post-course and 1 month later.

RESULTS

Seven nurses (71.4% female) were observed. Five (62.5%) initiated dialogue about CR, which lasted on average 12 s. Patients asked questions, which HCPs could not answer. The planning committee decided to develop an online course to reach inpatient cardiac HCPs, to educate them on how to encourage patients to participate in CR at the bedside. The course was pilot-tested with 5 HCPs (60.0% nurse-practitioners). Revisions included providing evidence of CR benefits and clarification regarding pre-CR stress test screening. HCPs did not remember the key points to convey, so a downloadable handout was embedded for the point-of-care. The course was launched, with the surveys. Twenty-four HCPs (83.3% nurses) completed the pre-course survey, 21 (87.5%) post, and 9 (37.5%) 1 month later. CR knowledge increased from pre (mean = 2.71 ± 0.95/5) to post-course (mean = 4.10 ± 0.62; p ≤ .001), as did self-efficacy in answering patient CR questions (mean = 2.29 ± 0.95/5 pre and 3.67 ± 0.58 post; p ≤ 0.001). CR attitudes were significantly more positive post-course (mean = 4.13 ± 0.95/5 pre and 4.62 ± 0.59 post; p ≤ 0.05). With regard to practice, 8 (33.3%) HCPs reported providing patients CR handouts pre-course at least sometimes or more, and 6 (66.7%) 1 month later.

CONCLUSIONS

Preliminary results support broader dissemination, and hence a genericized version has been created ( http://learnonthego.ca/Courses/promoting_patient_participation_in_CR_2020/promoting_patient_participation_in_CR_2020EN/story_html5.html ). Continuing education credits have been secured.

Feasibility and results of an intensive cardiac rehabilitation program. Insights from the MxM (Más por Menos) randomized trial

INTRODUCTION AND OBJECTIVES

Cardiac rehabilitation programs (CRP) are a set of interventions to improve the prognosis of cardiovascular disease by influencing patients' physical, mental, and social conditions. However, there are no studies evaluating the optimal duration of these programs. We aimed to compare the results of a standard vs a brief intensive CRP in patients after ST-segment elevation and non-ST-segment elevation acute coronary syndrome through the Más por Menos study (More Intensive Cardiac Rehabilitation Programs in Less Time).

METHODS

In this prospective, randomized, open, evaluator-blind for end-point, and multicenter trial (PROBE design), patients were randomly allocated to either standard 8-week CRP or intensive 2-week CRP with booster sessions. A final visit was performed 12 months later, after completion of the program. We assessed adherence to the Mediterranean diet, psychological status, smoking, drug therapy, functional capacity, quality of life, cardiometabolic and anthropometric parameters, cardiovascular events, and all-cause mortality during follow-up.

RESULTS

A total of 497 patients (mean age, 57.8±10.0 years; 87.3% men) were finally assessed (intensive: n=262; standard: n=235). Baseline characteristics were similar between the 2 groups. At 12 months, the results of treadmill ergometry improved by ≥ 1 MET in ≥ 93% of the patients. In addition, adherence to the Mediterranean diet and quality of life were significantly improved by CRP, with no significant differences between the groups. The occurrence of cardiovascular events was similar in the 2 groups.

CONCLUSIONS

Intensive CRP could be as effective as standard CRP in achieving adherence to recommended secondary prevention measures after acute coronary syndrome and could be an alternative for some patients and centers. Registered at ClinicalTrials.gov (Identifier: NCT02619422).

Sex Difference in Risk Factors, GRACE Scores, and Management among Post-Acute Coronary Syndrome Patients in Sri Lanka

Objective

To assess sex-based differences in the prevalence of risk factor, their management, and differences in the prognosis among acute coronary syndrome (ACS) in Sri Lanka.

Methods

Patients diagnosed with ACS were recruited from hospitals throughout the island. The Joint European Societies guidelines were used to assess recommended targets for coronary heart disease risk factors, and the GRACE score was used to assess the post-ACS prognosis. Age-adjusted regression was performed to calculate odds ratios for men versus women in risk factor control.

Results

A total of 2116 patients, of whom 1242 (58.7%) were men, were included. Significant proportion of women were nonsmokers; OR = 0.11 (95% CI 0.09 to 0.13). The prevalence of hypertension (p < 0.001), diabetes (p < 0.001), and dyslipidemia (p=0.004) was higher in women. The LDL-C target was achieved in a significantly higher percentage of women (12.6%); OR = 0.33 (95% CI 0.10 to 1.05). When stratified by age, no significant differences were observed in achieving the risk factor targets or management strategies used except for fasting blood sugar (p < 0.05) where more men achieved control target in both age categories. Majority of the ACS patients had either high or intermediate risk for one-year mortality as per the GRACE score. In-hospital and 1-year mean mortality risk was significantly higher among men of less than 65 years of age (p < 0.05).

Conclusions

Smoking is significantly lower among Sri Lankan women diagnosed with ACS. However, hypertension, diabetes, and dyslipidemia were more prevalent among them. There was no difference in primary and secondary preventive strategies and management in both sexes but could be further improved in both groups.

The effect of problem-based learning after coronary heart disease - a randomised study in primary health care (COR-PRIM)

BACKGROUND

Cardiac rehabilitation is effective after coronary heart disease (CHD). However, risk factors remain, and patients report fear for recurrence during recovery. Problem-based learning is a pedagogical method, where patients work self-directed in small groups with problem solving of real-life situations to manage CHD risk factors and self-care. We aimed to demonstrate the better effectiveness of problem-based learning over home-sent patient information for evaluating long-term effects of patient empowerment and self-care in patients with CHD. Hypothesis tested: One year of problem-based learning improves patients' empowerment- and self-efficacy, to change self-care compared to 1 year of standardised home-sent patient information after CHD.

METHODS

Patients (N = 157) from rural and urban areas in Sweden between 2011 and 2015 (78% male; age. 68 ± 8.5 years) with CHD verified by percutaneous coronary intervention (PCI) (70.1%) or coronary artery by-pass surgery (CABG) and CABG+PCI or myocardial infarction (29.9%) were randomly assigned to problem-based learning (experimental group; n = 79) or home-sent patient information (controls; n = 78). The problem-based learning intervention consisted of patient education in primary care by nurses tutoring groups of 6-9 patients on 13 occasions over 1 year. Controls received home-sent patient information on 11 occasions during the study year.

RESULTS

At one-year follow-up, the primary outcome, patient empowerment, did not significantly differ between the experimental group and controls. We found no significant differences between the groups regarding the secondary outcomes e.g. self-efficacy, although we found significant differences for body mass index (BMI) [- 0.17 (SD 1.5) vs. 0.50 (SD 1.6), P = 0.033], body weight [- 0.83 (SD) 4.45 vs. 1.14 kg (SD 4.85), P = 0.026] and HDL cholesterol [0.1 (SD 0.7) vs. 0.0 mmol/L (SD 0.3), P = 0.038] favouring the experimental group compared to controls.

CONCLUSIONS

The problem-based learning- and the home-sent patient information interventions had similar results regarding patient empowerment, self-efficacy, and well-being. However, problem-based learning exhibited significant effects on weight loss, BMI, and HDL cholesterol levels, indicating that this intervention positively affected risk factors compared to the home-sent patient information.

TRIAL REGISTRATION

NCT01462799 (February 2020).

Reduced 10-year risk of developing cardiovascular disease after participating in a lifestyle programme in primary care

Background: Despite well-known preventive effects for future cardiovascular disease (CVD) risk through lifestyle changes, scientific evaluations of lifestyle programmes in primary care are scarce. Moreover, structured lifestyle counselling is still not integrated in everyday clinical practice. We aimed to evaluate change in cardiovascular risk factors and Framingham 10-year risk score of developing CVD in men and women at high cardiovascular risk after participation in a structured lifestyle programme over 1 year. A single-group study was carried out with a 1-year follow-up including before and after measurements.Methods: The lifestyle programme comprised five appointments to a district nurse over 1 year, focussing on lifestyle habits based on motivational interviewing. Fasting blood samples and anthropometric measurements were obtained at baseline and 1-year follow-up. The 10-year risk of CVD was calculated according to Framingham general CVD risk score.Results: A total of 404 patients were included in the study. There was a positive change over 1 year in the total study population for all risk factors evaluated. This included improvements in weight, waist circumference, blood pressure, blood lipids, and fasting glucose. The 10-year risk of developing CVD decreased for the total population from 24.8% to 21.4% at 1 year, equivalent to a 14% decrease.Conclusions: A structured lifestyle programme in primary care contributes to significant improvements of cardiovascular risk factors and the reduction of 10-year risk for CVD for both men and women at high cardiovascular risk.

The prognostic importance of subclinical heart failure in stable coronary heart disease patients

Background: In stable coronary heart disease (CHD) patients we aimed to assess the predictive potential of only mild increase of brain natriuretic peptide (BNP) in subjects free from symptoms or diagnostic criteria of heart failure (HF).Methods: We examined 967 patients, at least 6 months after myocardial infarction or coronary revascularization and divided them into three categories: 'overt HF' (NYHA II-IV, objective signs of HF, chronic treatment with furosemide and/or spironolactone or history of hospitalisation for HF), 'subclinical HF (BNP over 150 ng/mL, but no criterion of overt HF)' and 'no HF' (no above mentioned criterion present). Follow-up was done to assess 5-years all-cause mortality.Results: Overt and subclinical HF (by definition) had 38.8% and 9.6% of patients, respectively. In analyses adjusted for classical risk factors and other possible covariates, both overt and subclinical HF were independently associated with increased mortality compared to no HF subjects [hazard risk ratio 1.99 (95%CI:1.02-3.91) and 3.01 (95%CI:1.90-4.78), respectively. The risk of total mortality was similar in overt and subclinical HF patients [HRR 1.30 (95%CI: 0.72-2.36)]. Within overt HF group, those with BNP >150 ng/mL had also higher mortality risk than those with low BNP levels [HRR 2.79 (95%CI: 1.67-4.68)]. The addition of left ventricle ejection fraction into definition of HF groups did not affect main results.Conclusions: Mild increase of BNP in generally stable and asymptomatic CHD patients identifies high individual mortality risk in the same extend that presence of clinically manifest HF.

Clinical outcomes, pharmacological treatment, and quality of life of patients with stable coronary artery diseases managed by cardiologists: 1-year results of the START study

AIMS

We evaluated the 1-year clinical events, pharmacological management, and quality of life in a contemporary cohort of stable coronary artery disease (CAD) patients managed by cardiologists.

METHODS AND RESULTS

START (STable Coronary Artery Diseases RegisTry) was a prospective, observational, nationwide study that enrolled 5070 stable CAD patients over 3 months in 183 cardiology centres in Italy. At 1 year, 4790 (94.5%) patients had data on vital status. Death occurred in 107 (2.2%) patients and the cause of death was cardiovascular in 41 (38.3%) of cases. Among the 4775 patients with follow-up data on clinical events available, a hospitalization due to cardiovascular and non-cardiovascular causes occurred in 523 (11.0%) and in 231 (4.8%) of cases, respectively. Over 60% of patients reported as 'no problems' in all domains (61.4-84.5%) of the EuroQoL quality of life 5D-5L questionnaire. Among the 3239 patients with clinical visit/telephone interview at follow-up, in whom optimal medical therapy (OMT; aspirin or thienopyridine, β-blocker, and statin) was prescribed at enrolment, 2971 (91.7%) were still receiving OMT at follow-up. At multivariable analysis, only increasing age (odds ratio 0.98; 95% confidence interval 0.97-0.99; P = 0.04) resulted as independent negative predictor of OMT persistence at 1 year from enrolment.

CONCLUSION

In this large, contemporary registry, stable CAD patients managed by cardiologists presented a high rate of clinical events at 1 year. Nevertheless, the persistence to OMT and quality of life appeared reasonable.

Healthy Promotion for Fighting Metabolic Syndrome: Insights from Multi-Center HeRO-FiT Cohort

We know that metabolic syndrome (MS) is a modern cardiovascular (CV) “epidemic”, especially in western populations. MS is indeed strictly related to the risk of developing CV diseases (CVD) and/or diabetes. Therefore, the aim of our multi-center study was to promote a “healthy style” for fighting MS. Each participating center analyzed its own database of outpatients and globally we have pulled out 100 volunteers to participate in the study. Before starting, we collected their written consent. Enrolled subjects have not any history of overt CVD and/or diabetes, but they matched National Cholesterol Education Program/Adult Treatment Panel (NCEP/ATP) criteria for MS. After enrolment (t0), subjects were randomly divided into two homogeneous groups: a) only diet suggestions; b) both diet and exercise prescription. Later, we measured for each subject: blood pressure (BP), heart rate (HR), height, weight, body mass index (BMI), waist circumference (WC), waist hip ratio (WHR), six-minute walking test (WT6M), distance and common blood tests such as fasting plasma glucose, high-density lipoproteins (HDL) and triglycerides (T1 assessments). At six months (T2), the same parameters were measured and then statistical comparisons were performed. Attention to diet caused significant changes only in WC and WHR, whilst a coupling of exercise and diet revealed a statistically significant improvement in HR, BP, BMI, blood samplings and WT6M too. In conclusion, a healthy lifestyle should be more encouraged by physicians and/or collaborators (such as dieticians) operating in preventive settings. Diet and physical activity may be early useful strategies in the “battle” against MS even before any medication choices. Further studies will be necessary in order to better address the topic.

Social Factors, Sex, and Mortality Risk After Coronary Artery Bypass Grafting: A Population-Based Cohort Study

Background Little is known of the impact of social factors on mortality after coronary artery bypass grafting ( CABG ). We explored sex- and age-specific associations between mortality risk after CABG and marital status, income, and education. Methods and Results This population-based register study included 110 742 CABG patients (21.3% women) from the SWEDEHEART registry (Swedish Web-system for Enhancement and Development of Evidence-based Care in Heart Disease Evaluated According to Recommended Therapies) operated 1992 to 2015. Cox regression models were used to study the relation between social factors and all-cause mortality. Never having been married compared with being married/cohabiting was associated with a higher risk in women than in men (hazard ratio 1.32, 95% CI 1.20-1.44) versus 1.17 (1.13-1.22), P=0.030 between sex. The lowest income quintile, compared with the highest, was associated with higher risk in men than in women (hazard ratio 1.44 [1.38-1.51] versus 1.25 [1.14-1.38], P=0.0036). Lowest education level was associated with higher risk without sex difference (hazard ratio 1.15 [1.11-1.19] versus 1.25 [1.16-1.35], P=0.75). For unmarried women aged 60 years at surgery with low income and low education, mortality 10 years after surgery was 18%, compared with 11% in married women with high income and higher education level. The median life expectancy was 4.8 years shorter. Corresponding figures for 60-year-old men were 21% versus 12% mortality risk at 10 years and 5.0 years shorter life expectancy. Conclusions There are strong associations between social factors and mortality risk after CABG in both men and women. These results emphasize the importance of developing and implementing secondary prevention strategies for CABG patients with disadvantages in social factors.

Blood pressure distribution and control in coronary patients from 24 European countries in the European Society of Cardiology EURoObservational Research Programme European survey of cardiovascular disease prevention and diabetes. EUROASPIRE IV Registry

BACKGROUND

Hypertension is the most prevalent major independent risk factor for developing coronary heart disease (CHD). The present analysis aimed to assess blood pressure (BP) distribution and factors associated with insufficient BP control in coronary patients from 24 countries participating in the European Society of Cardiology (ESC) EURoObservational Research Programme (EORP) EUROASPIRE IV survey.

METHODS

EUROASPIRE IV is a cross-sectional study conducted in 2012-2013 in patients aged 80 years or less hospitalized for CHD with a follow-up visit at a median of 16 months later. Logistic regression analysis was applied to confirm factors associated with BP control defined as less than 140/90 mmHg for nondiabetic patients and less than 140/85 mmHg for diabetic patients.

RESULTS

A total of 7998 patients (response rate, 48.7%) attended the follow-up visit. Complete data were available in 7653 participants (mean age 62.5 ± 9.6 years). The BP goal was achieved in 57.6%. Patients failing to achieve the BP goal were older, had higher BMI, had more often a history of coronary artery bypass grafting (CABG) and reported diabetes more frequently. Logistic regression confirmed the following independent significant predictors of not achieving the BP goal: a history of diabetes [odds ratio (OR) 1.75], obesity (OR 1.70 vs. normal BMI), overweight (OR 1.28 vs. normal BMI), age at least 65 years (OR 1.53) and CABG as the index event (OR 1.26 vs. acute MI).

CONCLUSION

EUROASPIRE IV found insufficient BP control in a large proportion of patients with stable CHD, with diabetes, increased BMI, older age and CABG as the index event being independent predictors of poor BP control.

Perceived Discrimination, Psychological Distress and Cardiovascular Risk in Migrants in Spain

The aim of the present study is to determine the effect of discrimination and psychological distress on the cardiovascular health of immigrants, as well as to analyse potential differences based on age, gender, length of residence in host country and geographic origin. The sample was formed by 1714 immigrants from Africa, Eastern Europe and Latin America. Of the sample, 48.7% were men and 51.3% were women. Most relevant results show that discrimination (t = 4.27; p = 0.000) and psychological distress (t = 4.35; p = 0.000) experienced by immigrants predict their cardiovascular risk. Furthermore, psychological distress mediates the relation between discrimination and risk (t = 4.03; p = 0.000). Significant differences between men and women were found, as well as differences based on ethnicity, although to a lesser extent. Age affects the relation between discrimination, psychological distress and arterial hypertension and hypercholesterolemia. Results are notably relevant for the design of preventive health programmes for immigrants and intervention strategies in order to prevent diseases that may imply cardiovascular risks and seriously affect immigrants' health.

Cardiac telerehabilitation as an alternative to centre-based cardiac rehabilitation

Multidisciplinary cardiac rehabilitation (CR) reduces morbidity and mortality and increases quality of life in cardiac patients. However, CR utilisation rates are low, and targets for secondary prevention of cardiovascular disease are not met in the majority of patients, indicating that secondary prevention programmes such as CR leave room for improvement. Cardiac telerehabilitation (CTR) may resolve several barriers that impede CR utilisation and sustainability of its effects. In CTR, one or more modules of CR are delivered outside the environment of the hospital or CR centre, using monitoring devices and remote communication with patients. Multidisciplinary CTR is a safe and at least equally (cost-)effective alternative to centre-based CR, and is therefore recommended in a recent addendum to the Dutch multidisciplinary CR guidelines. In this article, we describe the background and core components of this addendum on CTR, and discuss its implications for clinical practice and future perspectives.

Greater burden of risk factors and less effect of cardiac rehabilitation in elderly with low educational attainment: The Eu-CaRE study

AIMS

Socioeconomic status is a strong predictor of cardiovascular health. The aim of this study was to describe the immediate and long-term effects of cardiac rehabilitation (CR) across socioeconomic strata in elderly cardiac patients in Europe.

METHODS AND RESULTS

The observational EU-CaRE study is a prospective study with eight CR sites in seven European countries. Patients ≥65 years with coronary heart disease or heart valve surgery participating in CR were consecutively included. Data were obtained at baseline, end of CR and at one-year follow up. Educational level as a marker for socioeconomic status was divided into basic, intermediate and high. The primary endpoint was exercise capacity (peak oxygen consumption (VO2peak)). Secondary endpoints were cardiovascular risk factors, medical treatment and scores for depression, anxiety and quality of life (QoL). A total of 1626 patients were included; 28% had basic, 48% intermediate and 24% high education. A total of 1515 and 1448 patients were available for follow-up analyses at end of CR and one-year, respectively. Patients with basic education were older and more often female. At baseline we found a socioeconomic gradient in VO2peak, lifestyle-related cardiovascular risk factors, anxiety, depression and QoL. The socioeconomic gap in VO2peak increased following CR (p for interaction <0.001). The socioeconomic gap in secondary outcomes was unaffected by CR. The use of evidence-based medication was good in all socioeconomic groups.

CONCLUSIONS

We found a strong socioeconomic gradient in VO2peak and cardiovascular risk factors that was unaffected or worsened after CR. To address inequity in cardiovascular health, the individual adaption of CR according to socioeconomic needs should be considered.

The Beneficial Effects of Cardiac Rehabilitation

Cardiac rehabilitation (CR) is a combined range of measures aimed at providing patients with cardiovascular disease with the optimum psychological and physical conditions so that they themselves can prevent their disease from progressing or potentially reversing its course. The following measures are the three main parts of CR: exercise training, lifestyle modification, and psychological intervention. The course of cardiac rehabilitation generally takes 3-4 weeks.

A Personalized eHealth Intervention for Lifestyle Changes in Patients With Cardiovascular Disease: Randomized Controlled Trial

Background

Behavior change methods involving new ambulatory technologies may improve lifestyle and cardiovascular disease outcomes.

Objective

This study aimed to provide proof-of-concept analyses of an intervention aiming to increase (1) behavioral flexibility, (2) lifestyle change, and (3) quality of life. The feasibility and patient acceptance of the intervention were also evaluated.

Methods

Patients with cardiovascular disease (N=149; mean age 63.57, SD 8.30 years; 50/149, 33.5% women) were recruited in the Do Cardiac Health Advanced New Generation Ecosystem (Do CHANGE) trial and randomized to the Do CHANGE intervention or care as usual (CAU). The intervention involved a 3-month behavioral program in combination with ecological momentary assessment and intervention technologies.

Results

The intervention was perceived to be feasible and useful. A significant increase in lifestyle scores over time was found for both groups (F_2,146.6=9.99; P<.001), which was similar for CAU and the intervention group (F_1,149.9=0.09; P=.77). Quality of life improved more in the intervention group (mean 1.11, SD 0.11) than CAU (mean −1.47, SD 0.11) immediately following the intervention (3 months), but this benefit was not sustained at the 6-month follow-up (interaction: P=.02). No significant treatment effects were observed for behavioral flexibility (F_1,149.0=0.48; P=.07).

Conclusions

The Do CHANGE 1 intervention was perceived as useful and easy to use. However, no long-term treatment effects were found on the outcome measures. More research is warranted to examine which components of behavioral interventions are effective in producing long-term behavior change.

Trial Registration

ClinicalTrials.gov NCT02946281; https://www.clinicaltrials.gov/ct2/show/NCT02946281

Secondary prevention of coronary artery disease in Poland. Results from the POLASPIRE survey

BACKGROUND

The highest priority in preventive cardiology is given to patients with established coronary artery disease (CAD). The aim of the study was to assess the current implementation of the guidelines for secondary prevention in everyday clinical practice by evaluating control of the main risk factors and the cardioprotective medication prescription rates in patients following hospitalization for CAD.

METHODS

Fourteen departments of cardiology participated in the study. Patients (aged ≤ 80 years) hospitalized due an acute coronary syndrome or for a myocardial revascularization procedure were recruited and interviewed 6-18 months after the hospitalization.

RESULTS

Overall, 947 patients were examined 6-18 months after hospitalization. The proportion of patients with high blood pressure (≥ 140/90 mmHg) was 42%, with high low-density lipoprotein cholesterol (LDL-C ≥ 1.8 mmol/L) 62%, and with high fasting glucose (≥ 7.0 mmol/L) 22%, 17% of participants were smokers and 42% were obese. The proportion of patients taking an antiplatelet agent 6-18 months after hospitalization was 93%, beta-blocker 89%, angiotensin converting enzyme inhibitor or sartan 86%, and a lipid-lowering drug 90%. Only 2.3% patients had controlled all the five main risk factors well (non-smoking, blood pressure < 140/90 mmHg, LDL-C < 1.8 mmol/L and glucose < 7.0 mmol/L, body mass index < 25 kg/m2), while 17.9% had 1 out of 5, 40.9% had 2 out of 5, and 29% had 3 out of 5 risk factors uncontrolled.

CONCLUSIONS

The documented multicenter survey provides evidence that there is considerable potential for further reductions of cardiovascular risk in CAD patients in Poland. A revision of the state funded cardiac prevention programs seems rational.

Pharmacological management of modifiable cardiovascular risk factors (blood pressure and lipids) following diagnosis of myocardial infarction, stroke and diabetes: comparison between population-based studies in Russia and Norway

BACKGROUND

Cardiovascular disease (CVD) mortality is substantially higher in Russia than in neighbouring Norway. We aimed to compare blood pressure- and lipid-lowering medication use and proportion meeting treatment targets between general population samples in the two countries in those with CVD and diabetes.

METHODS

The study population was adults aged 40-69 years reporting a diagnosis of myocardial infarction (MI), stroke and/or diabetes participating in cross-sectional population-based studies in Russia (Know Your Heart (KYH) 2015-18 N = 626) and Norway (The Tromsø Study 2015-16 (Tromsø 7) N = 1353). Reported medications were coded according to the 2016 WHO Anatomical Therapeutic Chemical Classification system. Treatment targets were defined using the Joint European Societies guidelines for CVD prevention in clinical practice (2016).

RESULTS

Age- and sex-standardized prevalence of use of lipid-lowering medications was higher in Tromsø 7 for all three conditions with a disproportionately large difference in those reporting MI (+ 48% (95% CI 39, 57%)). Proportion meeting treatment targets for LDL cholesterol was poor in both studies (age- and sex-standardized prevalence of control KYH vs Tromsø 7: MI 5.1% vs 10.1%; stroke 11.6% vs 5.8%; diabetes 24.9% vs 23.3%). Use of antihypertensive medication was higher in KYH for stroke (+ 40% (95% CI 30, 50%)) and diabetes (+ 27% (95% CI 19, 34%)) groups but approximately equal for the MI group (- 1% (95% CI -1, 1%)). Proportion meeting blood pressure targets was lower in KYH vs Tromsø 7 (MI 51.8% vs 76.3%; stroke 49.5% vs 69.6%; diabetes 51.9% vs 63.9%).

CONCLUSIONS

We identified different patterns of medication use in people with CVD and diabetes. However despite higher use of lipid-lowering medication in the Norwegian study treatment to target for total cholesterol was poor in both Russian and Norwegian studies. In contrast we found higher levels of use of antihypertensive medications in the Russian study but also that less participants met treatment targets for blood pressure. Further work should investigate what factors are responsible for this seeming paradox and how management of modifiable risk factors for secondary prevention could be improved.

The need to improve cardiac care after acute coronary syndrome

Patients who experience acute coronary syndrome (ACS) are at increased risk of new cardiovascular (CV) events. The main strategies for prevention of recurrence of CV events is the protection from ruptured plaque, thrombus formation, occlusion or downstream embolization in the coronary artery. The percutaneous coronary intervention (PCI) with stenting and anticoagulants, 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitors (HMGCoAi, commonly called statins) and neurohormonal inhibition, has led to a notable decrease in 1-year mortality events. Today it is well documented that all patients with an ACS should be treated early, intensively and continuously for lowering the LDL-C values to the recommended goals. Regularly interviewing by trained health care personnel and post-discharge follow-up of patients after ACS seems to be more effective concerning adherence to statin for achieving LDL-C treatment goals compared with the standard of care.

Cardiovascular Risk Distribution in a Contemporary Polish Collective

The aim of this study was to assess the prevalence of selected risk factors for cardiovascular disease (hypertension, overweight, obesity, carbohydrate metabolism disorders, a positive family history, a lack of physical activity), and to estimate the risk of a cardiovascular incident according to the Systematic Coronary Risk Evaluation (SCORE) algorithm for patients aged 35, 40, 45, 50, and 55 years, included in a primary-care prevention program, with regard to selected variables (sex and age brackets). The study sample consisted of 2009 subjects, 63% of whom were women. The largest group was the group of 35-year-olds (27%). The research method was the analysis of medical documentation of primary-care patients living in West Pomerania included in the Program of Prevention and Early Detection of Cardiovascular Disease of the National Health Fund. We collected data concerning risk factors for cardiovascular disease, blood pressure, anthropometric measurements (arm circumference, waist circumference, height, weight), body mass index (BMI), and the levels of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides (TG), and fasting glucose, as well as the SCORE results. Men more often than women were overweight and obese, had hyperglycemia, and had elevated levels of total cholesterol, LDL cholesterol, and triglycerides (p < 0.001). There was also a statistically significant difference in the odds of a cardiovascular incident (p < 0.001)—the SCORE results obtained by men were higher. Men require special preventive measures in order to reduce their risk factors for cardiovascular disease, especially hypertension, dyslipidemia, diabetes, overweight, obesity, smoking, and a positive family history.

Prescribing and medical non-adherence after myocardial infarction: qualitative interviews with general practitioners in Germany

BACKGROUND

An increasing prevalence of having survived a myocardial infarction increases the importance of medical secondary prevention. Although preventive medication reduces mortality, prescribing and adherence are known to be frequently insufficient. General practitioners are the most important prescriber. However, their perspective on prescribing and medical non-adherence following myocardial infarction has not yet been explored. Thus, the aim of this study was to explore the general practitioners' perspective on long-term care after myocardial infarction focussing on medical prevention.

METHODS

In this qualitative interview study we conducted episodic interviews with sixteen general practitioners from rural and urban surgeries in Germany. Framework analysis with focus on general practitioners' prescribing and patients' non-adherence was performed.

RESULTS

Almost all general practitioners reported following guidelines for myocardial infarction aftercare and prescribing the medication that was initiated in the hospital; however, they described deviating from guidelines because of drugs' side effects or patients' intolerances. Some questioned the benefits of medical secondary prevention for the oldest of patients. General practitioners perceived good adherence among their patients who had had an MI while they regarded their methods for assessing medical non-adherence as limited. They perceived diverse reasons for non-adherence, particularly side effects, patients' freedom from symptoms and patients' indifference to health. They attributed mainly negative characteristics, like lack of knowledge and understanding, to non-adherent patients. These characteristics contribute to the difficulty of convincing these patients to take medications as prescribed. General practitioners improved adherence by preventing side effects, explaining the medication's necessity, facilitating intake and involving patients in decision-making. However, about half of the general practitioners reported threatening their patients with negative consequences of non-adherence.

CONCLUSIONS

General practitioners should be aware that discharge medication can be insufficient and thus, should always check hospital recommendations for accordance with guideline recommendations. Improving physicians' communication skills and informing and motivating patients in an adequate manner, for example in simple language, should be an important goal in the hospital and the general practitioner setting. General practitioners should assess patients' motivations through motivational interviewing, which no general practitioner mentioned during the interviews, and talk with them about adherence and long-term treatment goals regularly.

Proportion of High-Risk/Very High-Risk Patients in Europe with Low-Density Lipoprotein Cholesterol at Target According to European Guidelines: A Systematic Review

Objective

Assess achievement of low-density lipoprotein cholesterol (LDL-C) targets in European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) guidelines.

Design

Systematic literature review.

Data Sources

Medline, EMBASE, Cumulated Index to Nursing and Allied Health Literature.

Eligibility Criteria

Observational studies reporting LDL-C levels/target attainment, measured between 1 August 2006 to 31 August 2017, in European adults with established cardiovascular disease (CVD), diabetes with target organ damage, familial hypercholesterolaemia (FH) or 10-year risk of fatal CVD ≥ 5% (assessed by Systematic Coronary Risk Evaluation [SCORE]).

Data Extraction and Synthesis

Two reviewers independently extracted relevant studies and assessed study quality using the Risk of Bias for Non-Randomised Studies–Interventions (ROBINS-I) tool. Primary outcome was the proportion of patients achieving LDL-C targets in the 2011/2016 ESC/EAS guidelines. Where available, patient characteristics were presented as means weighted by sample size. The proportions of patients achieving LDL-C targets in the 5 years before and after publication of the 2011 guidelines were compared using a chi-square test.

Results

Across 81 eligible studies (303,534 patients), achievement of LDL-C < 1.8 mmol/L was poor among patients with established CVD (16%; range 9–56%) and at very high risk of CVD (SCORE ≥ 10% [18%; 14–25%]). In individuals with FH, SCORE 5–10%, or diabetes and target organ damage, LDL-C < 2.5 mmol/L was achieved by 15% (9–22%), 46% (21–55%) and 13% (6–34%), respectively. Comparing the 5 years before/after publication of the 2011 guidelines, target achievement increased significantly over time but remained suboptimal (LDL-C < 1.8, 22% versus 15%; LDL-C < 2.5, 68% versus 61%; both p < 0.001; established CVD group only).

Conclusions

These data show suboptimal LDL-C control among European patients at high risk of CVD. Those at greatest overall risk (clinically established CVD or at least a 10% 10-year risk of fatal CVD) had the lowest achievement of 2011/2016 EAS/ESC LDL-C targets. With lower LDL-C targets advocated in 2019 ESC/EAS guidelines, this unmet need will increase.

Protocol Registration

PROSPERO registration number; CRD77844

Electronic supplementary material

The online version of this article (10.1007/s12325-020-01285-2) contains supplementary material, which is available to authorized users.

Personalized eHealth Program for Life-style Change: Results From the "Do Cardiac Health Advanced New Generated Ecosystem (Do CHANGE 2)" Randomized Controlled Trial

OBJECTIVE

Unhealthy life-style factors have adverse outcomes in cardiac patients. However, only a minority of patients succeed to change unhealthy habits. Personalization of interventions may result in critical improvements. The current randomized controlled trial provides a proof of concept of the personalized Do Cardiac Health Advanced New Generation Ecosystem (Do CHANGE) 2 intervention and evaluates effects on a) life-style and b) quality of life over time.

METHODS

Cardiac patients (n = 150; mean age = 61.97 ± 11.61 years; 28.7% women; heart failure, n = 33; coronary artery disease, n = 50; hypertension, n = 67) recruited from Spain and the Netherlands were randomized to either the "Do CHANGE 2" or "care as usual" group. The Do CHANGE 2 group received ambulatory health-behavior assessment technologies for 6 months combined with a 3-month behavioral intervention program. Linear mixed-model analysis was used to evaluate the intervention effects, and latent class analysis was used for secondary subgroup analysis.

RESULTS

Linear mixed-model analysis showed significant intervention effects for life-style behavior (Finteraction(2,138.5) = 5.97, p = .003), with improvement of life-style behavior in the intervention group. For quality of life, no significant main effect (F(1,138.18) = .58, p = .447) or interaction effect (F(2,133.1) = 0.41, p = .67) was found. Secondary latent class analysis revealed different subgroups of patients per outcome measure. The intervention was experienced as useful and feasible.

CONCLUSIONS

The personalized eHealth intervention resulted in significant improvements in life-style. Cardiac patients and health care providers were also willing to engage in this personalized digital behavioral intervention program. Incorporating eHealth life-style programs as part of secondary prevention would be particularly useful when taking into account which patients are most likely to benefit.

TRIAL REGISTRATION

https://clinicaltrials.gov/ct2/show/NCT03178305.

Improvements in exercise capacity of older adults during cardiac rehabilitation

AIMS

Cardiac rehabilitation plays a vital role in secondary prevention of cardiovascular patients. Female sex and higher age, however, are associated with non-referral to cardiac rehabilitation. Improving exercise capacity during cardiac rehabilitation is essential to reduce morbidity and mortality risks. The objective of this study was to closely examine the beneficial changes in exercise capacity of older patients of both sexes during cardiac rehabilitation and to identify the most important predictors of the change in exercise capacity.

METHOD

A sample of 13,612 patients (mean age = 69.10 ± 11.8 years, 63.7% men, 19% > 80 years) was analysed. Data were prospectively assessed from 2012-2018 in six Swiss in-patient cardiovascular rehabilitation clinics. Improvement in exercise capacity measured with the six-minute walking test represents the outcome variable. Univariate and multivariate analyses, as well as the random forest method were used to estimate variable importance.

RESULTS

Mean improvement in the six-minute walking test was 113.5 ± 90.5 m (men = 118.7 ± 110.0; women = 104.4 ± 93.0, Cohen's d = 0.16). The presence of heart failure, diabetes mellitus and psychiatric diagnoses was related to reduced but nonetheless clinically relevant six-minute walking test improvement. Random forest analysis suggests that baseline exercise capacity, age, time in rehabilitation and heart failure were the most important predictors for improvement in exercise capacity. Clinically relevant improvements in exercise capacity (>45 m) were also present into old age (85 years) and for both sexes.

CONCLUSION

As indicated by these results, efforts need to be increased to refer eligible patients to structured rehabilitation programmes, irrespective of patients' age and sex.

Comparing the Attention Score Between American and European Cardiology Guidelines

INTRODUCTION

The American College of Cardiology (ACC) in USA and the European Society of Cardiology (ESC) in Europe have issued around 25 practice cardiology guidelines since 2008. The attention and impact of these guidelines have not been investigated yet.

AIM

In this study, we aim to compare the attention brought up by ACC and ESC guidelines.

METHODS

Guideline documents were defined as documents published by either the ACC or the ESC, where recommendations with a specific level of evidence are clearly indicated. These documents were posted on their respective websites. For each document, we extracted the attention on blogs, news, social media, and other platforms to calculate a total score known as the Altmetric Attention Score (AAS). Then we compared AAS, citations, and other indices between ACC and ESC guideline documents.

RESULTS

A total of 26 US and 24 European cardiology guidelines were released between 2008 and 2018. We found a significant difference in the median AAS between American and European guidelines (p = 0.048). The median AAS for European and for American guidelines were 159 (104.25-392.5) and 79 (24-169.75), respectively. The US Contribution to the AAS was significantly higher than the European in both the European guidelines (p < 0.001, median contribution values were 7.6% vs 3.4%, respectively), and the American guidelines (p = 0.011, median contribution values were 12% vs 7%, respectively).

CONCLUSION

The attention brought up by the European guideline documents was higher than the American guidelines, although most of the attention in both guidelines was contributed to by USA.

Low-Density Lipoprotein Cholesterol Target Attainment in Patients With Established Cardiovascular Disease: Analysis of Routine Care Data

BACKGROUND

Direct feedback on quality of care is one of the key features of a learning health care system (LHS), enabling health care professionals to improve upon the routine clinical care of their patients during practice.

OBJECTIVE

This study aimed to evaluate the potential of routine care data extracted from electronic health records (EHRs) in order to obtain reliable information on low-density lipoprotein cholesterol (LDL-c) management in cardiovascular disease (CVD) patients referred to a tertiary care center.

METHODS

We extracted all LDL-c measurements from the EHRs of patients with a history of CVD referred to the University Medical Center Utrecht. We assessed LDL-c target attainment at the time of referral and per year. In patients with multiple measurements, we analyzed LDL-c trajectories, truncated at 6 follow-up measurements. Lastly, we performed a logistic regression analysis to investigate factors associated with improvement of LDL-c at the next measurement.

RESULTS

Between February 2003 and December 2017, 250,749 LDL-c measurements were taken from 95,795 patients, of whom 23,932 had a history of CVD. At the time of referral, 51% of patients had not reached their LDL-c target. A large proportion of patients (55%) had no follow-up LDL-c measurements. Most of the patients with repeated measurements showed no change in LDL-c levels over time: the transition probability to remain in the same category was up to 0.84. Sequence clustering analysis showed more women (odds ratio 1.18, 95% CI 1.07-1.10) in the cluster with both most measurements off target and the most LDL-c measurements furthest from the target. Timing of drug prescription was difficult to determine from our data, limiting the interpretation of results regarding medication management.

CONCLUSIONS

Routine care data can be used to provide feedback on quality of care, such as LDL-c target attainment. These routine care data show high off-target prevalence and little change in LDL-c over time. Registrations of diagnosis; follow-up trajectory, including primary and secondary care; and medication use need to be improved in order to enhance usability of the EHR system for adequate feedback.

Screening for Glucose Perturbations and Risk Factor Management in Dysglycemic Patients With Coronary Artery Disease-A Persistent Challenge in Need of Substantial Improvement: A Report From ESC EORP EUROASPIRE V

OBJECTIVE

Dysglycemia, in this survey defined as impaired glucose tolerance (IGT) or type 2 diabetes, is common in patients with coronary artery disease (CAD) and associated with an unfavorable prognosis. This European survey investigated dysglycemia screening and risk factor management of patients with CAD in relation to standards of European guidelines for cardiovascular subjects.

RESEARCH DESIGN AND METHODS

The European Society of Cardiology's European Observational Research Programme (ESC EORP) European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) V (2016-2017) included 8,261 CAD patients, aged 18-80 years, from 27 countries. If the glycemic state was unknown, patients underwent an oral glucose tolerance test (OGTT) and measurement of glycated hemoglobin A_1c. Lifestyle, risk factors, and pharmacological management were investigated.

RESULTS

A total of 2,452 patients (29.7%) had known diabetes. OGTT was performed in 4,440 patients with unknown glycemic state, of whom 41.1% were dysglycemic. Without the OGTT, 30% of patients with type 2 diabetes and 70% of those with IGT would not have been detected. The presence of dysglycemia almost doubled from that self-reported to the true proportion after screening. Only approximately one-third of all coronary patients had completely normal glucose metabolism. Of patients with known diabetes, 31% had been advised to attend a diabetes clinic, and only 24% attended. Only 58% of dysglycemic patients were prescribed all cardioprotective drugs, and use of sodium-glucose cotransporter 2 inhibitors (3%) or glucagon-like peptide 1 receptor agonists (1%) was small.

CONCLUSIONS

Urgent action is required for both screening and management of patients with CAD and dysglycemia, in the expectation of a substantial reduction in risk of further cardiovascular events and in complications of diabetes, as well as longer life expectancy.

ASPIRE-3-PREVENT: a cross-sectional survey of preventive care after a coronary event across the UK

OBJECTIVE

To quantify the implementation of the third Joint British Societies' Consensus Recommendations for the Prevention of Cardiovascular Disease (JBS3) after coronary event.

METHODS

Using a cross-sectional survey design, patients were consecutively identified in 36 specialist and district general hospitals between 6 months and 2 years, after acute coronary syndrome or revascularisation procedure and invited to a research interview. Outcomes included JBS3 lifestyle, risk factor and therapeutic management goals. Data were collected using standardised methods and instruments by trained study nurses. Blood was analysed in a central laboratory and a glucose tolerance test was performed.

RESULTS

3926 eligible patients were invited to participate and 1177 (23.3% women) were interviewed (30% response). 12.5% were from black and minority ethnic groups. 45% were persistent smokers, 36% obese, 52.9% centrally obese, 52% inactive; 30% had a blood pressure >140/90 mm Hg, 54% non-high-density lipoprotein ≥2.5 mmol/L and 44.3% had new dysglycaemia. Prescribing was highest for antiplatelets (94%) and statins (85%). 81% were advised to attend cardiac rehabilitation (86% <60 years vs 79% ≥60 years; 82% men vs 77% women; 93% coronary artery bypass grafting vs 59% unstable angina), 85% attended if advised; 69% attended overall. Attenders were significantly younger (p=0.03) and women were less likely to attend (p=0.03).

CONCLUSIONS

Patients with coronary heart disease (CHD) are not being adequately managed after event with preventive measures. They require a structured preventive cardiology programme addressing lifestyle, risk factor management and adherence to cardioprotective medications to achieve the standards set by the British Association for Cardiovascular Prevention and Rehabilitation and JBS3 guidelines.

Factors associated with smoking cessation in patients with coronary heart disease: a cohort analysis of the German subset of EuroAspire IV survey

Background

Tobacco smoking is one of the most important risk factors of coronary heart disease (CHD). Hence, smoking cessation is considered pivotal in the prevention of CHD. The current study aimed to evaluate smoking cessation patterns and determine factors associated with smoking cessation in patients with established CHD.

Methods

The fourth European Survey of Cardiovascular Disease Prevention and Diabetes investigated quality of CHD care in 24 countries across Europe in 2012/13. In the German subset, smoking cessation patterns and clinical characteristics were repetitively assessed a) during index event due to CHD by medical record abstraction, b) as part of a face-to-face interview 6 to 36 months after the index event (i.e. baseline visit), and c) by telephone-based follow-up interview two years after the baseline visit. Logistic regression analysis was performed to search for factors determining smoking status at the time of the telephone interview.

Results

Out of 469 participants available for follow-up, 104 (22.2%) had been classified as current smokers at the index event. Of those, 65 patients (62.5%) had quit smoking at the time of the telephone interview, i.e., after a median observation period of 3.5 years (quartiles 3.0, 4.1). Depressed mood at baseline visit and higher education level were less prevalent amongst quitters vs non-quitters (17.2% vs 35.9%, p = 0.03 and 15.4% vs 33.3%, p = 0.03), cardiac rehabilitation programs were more frequently attended by quitters (83.1% vs 48.7%, p < 0.001), and there was a trend for a higher prevalence of diabetes at baseline visit in quitters (37.5% vs 20.5%, p = 0.07). In the final multivariable model, cardiac rehabilitation was associated with smoking cessation (OR 5.19; 95%CI 1.87 to 14.46; p = 0.002).

Discussion

Attending a cardiac rehabilitation program after a cardiovascular event was associated with smoking cessation supporting its use as a platform for smoking cessation counseling and relapse prevention.

Correlates of Blood Pressure and Cholesterol Level Testing Among a Socially-Disadvantaged Population in Poland

As part of cardiovascular disease prevention, the performance of BMI determination, blood pressure measurement, biochemical tests, as well as a lifestyle-related risk assessment are recommended. The aim of this study was to evaluate the correlates of blood pressure and cholesterol level testing among a socially-disadvantaged population in Poland. This cross-sectional study was performed between 2015 and 2016 among 1710 beneficiaries of government welfare assistance. Face-to-face interviews conducted by trained staff at each participant’s place of residence allowed for completion of questionnaires that covered socio-demographic, health and lifestyle-related information. Sixty-five percent of the participants declared a blood pressure and 27% of them cholesterol level testing at least once within the year proceeding the study. A higher chance of having blood pressure testing was observed among the women (OR = 1.5; p = 0.002) and people with high blood pressure (OR = 3.9; p < 0.001). The women (OR = 1.4; p = 0.04) and older people (OR = 1.9; p = 0.02; OR = 2.6; p < 0.001, OR = 2.7; p = 0.002, for the following age groups: 30-39, 40-49, 50-59 years respectively), the respondents who declared health problems such as heart attack (OR = 3.0; p = 0.04), high blood pressure (OR = 2.3; p < 0.001) and type 2 diabetes (OR = 3.3; p = 0.004) and those with a family history of chronic diseases (OR = 1.5; p = 0.03) had a higher chance of cholesterol level checking. Higher healthy lifestyle index, indicating that the study participants have followed almost all of the studied lifestyle-related recommendations, was a significant correlate of cholesterol level testing (OR = 1.7; p = 0.006). Actions that promote lifestyle changes, blood pressure, and cholesterol level testing should take into account the needs of the disadvantaged population and should especially target men, people with existing chronic diseases, and those with unfavorable lifestyle characteristics. With respect to the socially-disadvantaged population, the social assistance institutions and outpatient clinics are the best places to conduct activities promoting a healthy lifestyle. The most commonly applied strategies to promote lifestyle changes can cover risk assessment, increasing awareness, emotional support and encouragement, as well as a referral to specialists.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Patients who do not complete cardiac rehabilitation have an increased risk of cardiovascular events during long-term follow-up

Background

Cardiac rehabilitation (CR) has favourable effects on cardiovascular mortality and morbidity. Therefore, it might reasonable to expect that incomplete CR participation will result in suboptimal patient outcomes.

Methods

We studied the 914 post-acute coronary syndrome patients who participated in the OPTImal CArdiac REhabilitation (OPTICARE) trial. They all started a ‘standard’ CR programme, with physical exercises (group sessions) twice a week for 12 weeks. Incomplete CR was defined as participation in <75% of the scheduled exercise sessions. Patients were followed-up for 2.7 years, and the incidence of cardiac events was recorded. Major adverse cardiac events (MACE) included all-cause mortality, non-fatal myocardial infarction and coronary revascularisation.

Results

A total of 142 (16%) patients had incomplete CR. They had a higher incidence of MACE than their counterparts who completed CR (11.3% versus 3.8%, adjusted hazard ratio [aHR] 2.86 and 95% confidence interval [CI] 1.47–5.26). Furthermore, the incidence of any cardiac event, including MACE and coronary revascularisation, was higher (20.4% versus 11.0%, aHR 1.54; 95% CI 0.98–2.44). Patients with incomplete CR were more often persistent smokers than those who completed CR (31.7% versus 11.5%), but clinical characteristics were similar otherwise.

Conclusion

Post-ACS patients who did not complete a ‘standard’ 12-week CR programme had a higher incidence of adverse cardiac events during long-term follow-up than those who completed the programme. Since CR is proven beneficial, further research is needed to understand the reasons why patients terminate prematurely.

Prevalence and Correlates of Statin Underuse for Secondary Prevention of Cardiovascular Disease in Older Adults 65-79 Years of Age: The Italian Health Examination Survey 2008-2012

Limited data are available on the prevalence and correlates of statin use for secondary cardiovascular (CV) prevention in the older adult population. We used data of older adults (65-79 years) with established atherosclerotic CV disease from the cross-sectional Italian Health Examination Survey 2008-2012 to address this issue. Lifestyles, CV risk factors, chronic diseases, and therapies were assessed using standardized procedures. A comprehensive geriatric assessment was performed to evaluate cognitive function, disability in basic activities of daily living/instrumental activities of daily living, mobility, and polypharmacy. Multiple regression analyses were performed to identify independent correlates of statin use. A total of 392 participants (mean age 72.1 ± 4.4 years, 61.5% men) were considered for this analysis. Coronary heart disease was identified in 67.1% of participants, cerebrovascular disease in 23.5%, and peripheral artery disease (PAD) in 18.1%. One hundred ninety (48.5%) were statin users. By multiple regression analysis, functional disability (odds ratio [OR] = 0.81; 95% confidence interval [CI] = 0.71-0.92; p = 0.002), cognitive impairment (OR = 0.87; 95% CI = 0.78-0.98; p = 0.018), and polypharmacy (OR = 0.86; 95% CI = 0.75-0.98; p = 0.035) predicted statin nonuse, whereas having hypertension (OR = 1.19; 95% CI = 1.05-1.34; p = 0.005), diabetes mellitus (OR = 1.14; 95% CI = 1.03-1.27; p = 0.013), or a previous myocardial revascularization (OR = 1.31; 95% CI = 1.16-1.48; p < 0.001) predicted statin use. Significant interaction terms were observed between cerebrovascular disease, PAD, cognitive impairment, and disability in predicting statin nonuse. Statin underuse in older adults aged 65-79 years with CV disease, and thus suboptimal secondary CV prevention, is highly prevalent despite current guidelines and recommendations. Common geriatric conditions are associated with statin nonuse. Such results support the need for improving the awareness of statin treatment for secondary CV prevention.

A 2020 Vision of Hypertension

Hypertension is a common chronic disease affecting a large section of the general population. Hypertension is highly prevalent in the elderly because blood pressure (BP) rises with age. The risk of developing hypertension increases with predisposing genes, intrauterine growth retardation, prematurity and childhood obesity. BP is easier to control in the young. Non-pharmacological treatment through lifestyle changes, such as weight control and leisure-time physical activity, is more likely to be successful in young people. Hypertension in older adults is more difficult to control, requiring the use of more than one antihypertensive drug. Adverse effects and compliance become problematic. Much research is now directed at novel ways of controlling BP such as denervation. The change in definition of hypertension in the American guideline highlights the need to identify and manage hypertension early, at a stage when it is potentially reversible.

Urolithin A exerts antiobesity effects through enhancing adipose tissue thermogenesis in mice

Obesity leads to multiple health problems, including diabetes, fatty liver, and even cancer. Here, we report that urolithin A (UA), a gut-microflora-derived metabolite of pomegranate ellagitannins (ETs), prevents diet-induced obesity and metabolic dysfunctions in mice without causing adverse effects. UA treatment increases energy expenditure (EE) by enhancing thermogenesis in brown adipose tissue (BAT) and inducing browning of white adipose tissue (WAT). Mechanistically, UA-mediated increased thermogenesis is caused by an elevation of triiodothyronine (T3) levels in BAT and inguinal fat depots. This is also confirmed in UA-treated white and brown adipocytes. Consistent with this mechanism, UA loses its beneficial effects on activation of BAT, browning of white fat, body weight control, and glucose homeostasis when thyroid hormone (TH) production is blocked by its inhibitor, propylthiouracil (PTU). Conversely, administration of exogenous tetraiodothyronine (T4) to PTU-treated mice restores UA-induced activation of BAT and browning of white fat and its preventive role on high-fat diet (HFD)-induced weight gain. Together, these results suggest that UA is a potent antiobesity agent with potential for human clinical applications.

Cardiovascular risk in mild to moderately decreased glomerular filtration rate, diabetes and coronary heart disease in a southern European region

INTRODUCTION AND OBJECTIVES

Individuals with mild to moderately decreased estimated glomerular filtration rate (eGFR=30-59 mL/min/1.73 m²) are considered at high risk of cardiovascular disease (CVD). No studies have compared this risk in eGFR=30-59, diabetes mellitus (DM), and coronary heart disease (CHD) in regions with a low incidence of CHD.

METHODS

We performed a retrospective cohort study of 122 443 individuals aged 60-84 years from a region with a low CHD incidence with creatinine measured between January 1, 2010 and December 31, 2011. We identified hospital admissions due to CHD (myocardial infarction, angina) or CVD (CHD, stroke, or transient ischemic attack) from electronic medical records up to December 31, 2013. We estimated incidence rates and Cox regression adjusted subdistribution hazard ratio (sHR) including competing risks in patients with eGFR=30-59, DM and CHD, or combinations, compared with individuals without these diseases.

RESULTS

The median follow-up was 38.3 [IQR, 33.8-42.7] months. Adjusted sHR for CHD in individuals with eGFR=30-59, DM, eGFR=30-59 plus DM, previous CHD, CHD plus DM, and CHD plus eGFR=30-59 plus DM, were 1.34 (95%CI, 1.04-1.74), 1.61 (95%CI, 1.36-1.90), 1.96 (95%CI, 1.42-2.70), 4.33 (95%CI, 3.58-5.25), 7.05 (5.80-8.58) and 7.72 (5.72-10.41), respectively. The corresponding sHR for CVD were 1.25 (95%CI, 1.06-1.46), 1.56 (95%CI, 1.41-1.74), 1.83 (95%CI, 1.50-2.23), 2.86 (95%CI, 2.48-3.29), 4.54 (95%CI, 3.93-5.24), and 5.33 (95%CI, 4.31-6.60).

CONCLUSIONS

In 60- to 84-year-olds with eGFR=30-59, similarly to DM, the likelihood of being admitted to hospital for CHD and CVD was about half that of individuals with established CHD. Thus, eGFR=30-59 does not appear to be a coronary-risk equivalent. Individuals with CHD and DM, or eGFR=30-59 plus DM, should be prioritized for more intensive risk management.

Impact of intensively lowered low-density lipoprotein cholesterol on deferred lesion prognosis

OBJECTIVES

The aim of this study was to investigate the impact of intensively lowered low-density lipoprotein cholesterol (LDL-C) level on the deferred lesion prognosis after revascularization deferral based on fractional flow reserve (FFR).

BACKGROUND

Lowering LDL-C is associated with lower cardiovascular event rate, but its benefit on the deferred lesion prognosis has not been well evaluated.

METHODS

This retrospective, single-center, observational study analyzed 192 deferred lesions with FFR value >0.80 in 192 patients with stable coronary artery disease. According to the first follow-up LDL-C level, they were assigned to the LOW group (<70 mg/dL) or the HIGH group (≥70 mg/dL). Deferred lesion failure (DLF) was defined as the composite of deferred lesion revascularization and deferred vessel myocardial infarction.

RESULTS

Of all participants, 61 and 131 patients were assigned to the LOW and the HIGH group, respectively. During the median follow-up of 2.8 years, DLF occurred in 1 and 14 patients in the LOW group and the HIGH group (1.6% and 10.7%, log-rank p = .043), respectively. The incidence of any unplanned revascularization was also significantly lower in the LOW group than in the HIGH group (3.3% vs. 14.5%, log-rank p = .032).

CONCLUSIONS

The incidence of DLF was significantly lower in the patients with LDL-C < 70 mg/dL than in those with LDL-C ≥ 70 mg/dL at the first follow-up after FFR-based deferral of revascularization.

Dietary measures among patients with coronary heart disease in Europe. ESC EORP Euroaspire V

OBJECTIVE

Assess the dietary recommendations provided to patients hospitalized for a coronary heart disease (CHD) event.

DESIGN

Cross-sectional, multicentre observational study (ESC EORP Euroaspire V).

METHODS

8261 participants (25.8% women, 9.3% aged<50 years) from 27 countries, 6 to 24 months after hospitalization for a CHD event were included. Participants were asked if they had been advised to reduce salt, fat or sugar intake, change type of fat consumed, and increase consumption of plant stanols/sterols, fruit & vegetables, fish and oily fish. Self-reported changes were recorded.

RESULTS

Advice to reduce energy intake, salt, fat and sugar was provided to 64.5% [range: 9.2-90.5], 73.2% [38.6-95.2], 77.3% [42.3-95.6] and 67.0% [39.4-93.3] of patients, respectively. Advice to change fat type, increase consumption of plant stanols/sterols, fruit & vegetables, fish and oily fish was provided to 68.3% [33.7-92.3], 36.7% [0.6-75.2], 73.2% [39.2-93.6], 66.5% [8.0-90.8] and 53.5% [3.7-83.3] of patients, respectively. Advices were more frequently provided to patients aged 50 to 69, with a high educational level, or obesity. One-eighth [0-55.0] of patients reported having consulted a dietician. Reductions in energy intake, salt, fat and sugar were reported by 57.7% [4.9-81.0], 69.9% [32.1-85.9], 71.8% [40.4-88.4] and 61.2% [29.0-84.0] of patients, respectively. Changes in fat type and increased consumption of plant stanols/sterols, fruit & vegetables, fish and oily fish were reported by 60.9% [4.9-81.0], 25.8% [0.6-54.1], 69.2% [27.7-88.4], 54.8% [4.0-80.1] and 40.4% [2.0-66.8] of patients, respectively.

CONCLUSION

Dietary advice is not systematically provided to patients with CHD, and considerable differences exist between European countries.