Explaining the Decline in Coronary Heart Disease Mortality in Portugal Between 1995 and 2008

Fast-track referral for health interventions during pregnancy: study protocol of a randomised pragmatic experimental study to reduce low birth weight in Portugal (STOP LBW)

INTRODUCTION

Low birth weight (LBW) is associated with a wide range of short-term and long-term consequences and is related to maternal psychosocial and behavioural determinants. The objective of this study is to estimate the effect of implementing fast-track referral for early intervention on psychosocial and behavioural risk factors-smoking, alcohol consumption, depression and physical violence-in reducing the incidence of LBW.

METHODS AND ANALYSIS

Parallel superiority pragmatic clinical trial randomised by clusters. Primary healthcare units (PHCU) located in Portugal will be randomised (1:1) to intervention or control groups. Pregnant women over 18 years of age attending these PHCU will be eligible to the study. Risk factors will be assessed through face-to-face interviews. In the intervention group, women who report at least one risk factor will have immediate access to referral services. The comparison group will be the local standard of care for these risk factors. We will use intention-to-treat analyses to compare intervention and control groups. We estimated a sample size of 2832 pregnant women to detect a 30% reduction in the incidence rate of LBW between the control and intervention groups. Secondary outcomes are the reduction of preterm births, reduction of the four risk factors and acceptance of the intervention.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of the Public Health Institute of the University of Porto (no CE20140). The findings will be disseminated to the public, the funders, health professionals, health managers and other researchers.

TRIAL REGISTRATION NUMBER

NCT04866277.

The impact of clinical and population strategies on coronary heart disease mortality: an assessment of Rose's big idea

BACKGROUND

Coronary heart disease (CHD), the leading cause of death worldwide, has declined in many affluent countries but it continues to rise in industrializing countries.

OBJECTIVE

To quantify the relative contribution of the clinical and population strategies to the decline in CHD mortality in affluent countries.

DESIGN

Meta-analysis of cross-sectional and prospective studies.

DATA SOURCES

PubMed and Web of Science from January 1, 1970 to December 31, 2019.

METHOD

We combined and analyzed data from 22 cross-sectional and prospective studies, representing 500 million people, to quantify the relative decline in CHD mortality attributable to the clinical strategy and population strategy.

RESULT

The population strategy accounted for 48% (range = 19 to 73%) of the decline in CHD deaths and the clinical strategy accounted for 42% (range = 25 to 56%), with moderate inconsistency of results across studies.

CONCLUSION

Since 1970, a larger fraction of the decline in CHD deaths in industrialized countries was attributable to reduction in CHD risk factors than medical care. Population strategies, which are more cost-effective than clinical strategies, are under-utilized.

Intervention and in-hospital pharmacoterapies in octogenarian with acute coronary syndrome: a 10-year retrospective analysis of the Malaysian National Cardiovascular Database (NCVD) registry

BACKGROUND

Octogenarians and beyond have often been neglected in the populational study of disease despite being at the highest point of non-modifiable disease risk burden and the fastest-growing age group for the past decade. This study examined the characteristics and in-hospital management of octogenarian patients with acute coronary syndrome (ACS) in a multi-ethnic, middle-income country in South East Asia.

METHOD

This retrospective study utilised the Malaysian National Cardiovascular Disease- ACS (NCVD-ACS) registry. Consecutive patient data of those ≥80 years old admitted with ACS at 24 participating hospitals from 2008 to 2017 (n = 3162) were identified. Demographics, in-hospital intervention, and evidence-based pharmacotherapies over the 10-years were examined and compared across groups of interests using the Chi-square test. Multivariate logistic regression was used to calculate the adjusted odds ratio of receiving individual therapies according to patients' characteristics.

RESULTS

Octogenarians made up 3.8% of patients with ACS in the NCVD-ACS registry (mean age = 84, SD ± 3.6) from 2008 until 2017. The largest ethnic group was Chinese (44%). Most octogenarians (95%) have multiple cardiovascular risk factors, with hypertension (82%) being the main. Non-ST-elevation myocardial infarction (NSTEMI) predominated (38%, p < 0.001). Within the 10-year, there were positive increments in cardiovascular intervention and pharmacotherapies. Only 10% of octogenarians with ACS underwent percutaneous coronary intervention (PCI), the majority being STEMI patients (17.5%; p < 0.05). More than 80% were prescribed aspirin (91.3%) either alone or combined, dual antiplatelet therapy (DAPT) (83.3%), anticoagulants (89.7%) and statins (89.6%), while less being prescribed angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (47.6%) and beta-blockers (43.0%). Men were more likely to receive PCI than women (adjusted Odds Ratio (aOR): 0.698; 95% CI: 0.490-0.993). NSTEMI (aOR = 0.402, 95% CI: 0.278-0.583) and unstable angina (UA) (aOR = 0.229, 95% CI: 0.143-0.366) were less likely to receive PCI but more likely given anticoagulants (NSTEMI, aOR = 1.543, 95% CI: 1.111-2.142; UA, aOR = 1.610, 95% CI: 1.120-2.314) than STEMI. The presence of cardiovascular risk factors and comorbidities influences management.

CONCLUSION

Octogenarians with ACS in this country were mainly treated with cardiovascular pharmacotherapies. As the number of octogenarians with ACS will continue to increase, the country needs to embrace the increasing use of PCI in this group of patients.

Comparison of risk assessment tools for cardiovascular diseases: results of an Iranian cohort study

OBJECTIVES

Several popular cardiovascular risk assessment tools have been developed in Western countries; however, the predictive abilities of these tools have not been evaluated in Middle Eastern countries. The present study aimed to determine the abilities of cardiovascular risk assessment tools in a population-based study in Northern Iran.

STUDY DESIGN

Population-based cohort study in Northern Iran.

METHODS

In total, 2883 individuals (1629 men and 1254 women), aged 40-74 years, were included in the study. We determined the predictive abilities of the American College of Cardiology/American Heart Association (ACC/AHA) risk prediction tool, the Framingham general cardiovascular risk profile in primary care settings, and the Systematic Coronary Risk Evaluation (SCORE) equations for low- and high-risk European countries. Receiver operating characteristic (ROC) analysis was used to determine the predictive abilities of these four risk assessment tools.

RESULTS

Based on areas under curve (AUC) values and related 95% confidence intervals (95% CIs), the discriminative abilities of the ACC/AHA tool, the Framingham approach, and the SCORE for low- and high-risk European countries to estimate non-fatal cardiovascular disease (CVD) events were 0.6625, 0.6517, 0.6476 and 0.6458, respectively, in men, and 0.7722, 0.7525, 0.7330 and 0.7331, respectively, in women. Moreover, the abilities of these four tools to estimate fatal CVD events were found to be 0.8614, 0.8329, 0.7996 and 0.7988 in men, and 0.8779, 0.8372, 0.8535 and 0.8518 in women, respectively.

CONCLUSIONS

The cardiovascular risk assessment tools investigated in this study showed acceptable predictive abilities in women. The ACC/AHA approach showed slightly better performance compared with the SCORE tool; however, the SCORE tool benefited from the lowest cost compared with all the other tools.

Feasibility of cardiovascular risk screening in Portuguese community pharmacies

Background:

Cardiovascular disease (CVD) remains the leading cause of human mortality. As highly accessible and qualified health professionals, community pharmacists can be included in the early detection of patients at risk for CVD by implementing CVD screening programs.

Objective:

To assess the feasibility of CVD risk screening services in Portuguese community pharmacies from the evaluation of customers acceptability.

Methods:

A cross-sectional study was conducted in a community pharmacy in Portugal. The purpose of entering the pharmacy was recorded for all customers. Afterwards, the customers were invited to be interviewed by the pharmacist, who registered their willingness to participate and collected the participants’ data and biochemical and physical parameters to assess their CV risk by applying the Systematic COronary Risk Evaluation (SCORE) model. For the participants who were not eligible for the SCORE-based risk assessment, the pharmacist considered the major modifiable CVD risk factors - hypertension, dyslipidemia, smoking habits, obesity, impaired fasting glucose and sedentary behavior - according to the ESC guidelines.

Results:

Picking up medication was the most prevalent reason 69.8% (n=1,600) for entering the pharmacy, and among the contacted customers, 56.4% (n=621) agreed to have their CVD risk assessed. Of the 588 participants, 56.6% (n=333) were already on CV pharmacotherapy and were therefore not eligible for screening. Of the 43.4% (n=255) CV pharmacotherapy-naïve participants, 94.9% (n=242) were screened with at least one CVD risk factor; 52.9% (n=135) were not eligible for the SCORE assessment, of which 92.6% (n=125) presented CVD risk factors. Of the 120 SCORE eligible participants, 80.0% (n=96) were at least at moderate risk of CVD.

Conclusions:

We determined the feasibility of CVD risk screening in Portuguese community pharmacies, as we found high customer acceptability, noted the reasons for nonattendance, and found a high prevalence of CVD risk factors in at-risk patients. This is an opportunity for Portuguese community pharmacists to take a leading role in the early detection of CVD.

Impact of Antecedent Aspirin Use on Infarct Size, Bleeding and Composite Endpoint in Patients with de Novo Acute Myocardial Infarction

BACKGROUND

The study aimed to evaluate the impact of antecedent aspirin use on infarct size, bleeding and composite endpoint in patients with de novo acute myocardial infarction.

PATIENTS AND METHODS

A total of 562 consecutive patients with de novo acute myocardial infarction were included in this prospective cohort study. Patients were assigned into two groups based on presence (n=212) and absence (n=350) of prior aspirin use. Primary endpoint was myocardial infarct size, as estimated by troponin I peak. In-hospital mortality, bleeding and composite clinical endpoint including cardiogenic shock, stroke, in-hospital mortality and major bleeding were also evaluated.

RESULTS

Although GRACE and CRUSADE scores were higher, troponin I peak was lower in prior aspirin users. This result was maintained after adjustment for baseline ischemic risk profile and other major confounders including MI type and location. Despite high CRUSADE score, there was no increase in major and minor bleeding. Minimal bleeding was higher in antecedent aspirin users. When it was adjusted for the CRUSADE score, a similar risk was reported.

CONCLUSION

Patients with de novo acute myocardial infarction using aspirin for primary prevention have an unexpectedly smaller infarct size and similar bleeding rates.

Explaining the increment in coronary heart disease mortality in Mexico between 2000 and 2012

BACKGROUND

Mexico is still in the growing phase of the epidemic of coronary heart disease (CHD), with mortality increasing by 48% since 1980. However, no studies have analyzed the drivers of these trends. We aimed to model CHD deaths between 2000 and 2012 in Mexico and to quantify the proportion of the mortality change attributable to advances in medical treatments and to changes in population-wide cardiovascular risk factors.

METHODS

We performed a retrospective analysis using the previously validated IMPACT model to explain observed changes in CHD mortality in Mexican adults. The model integrates nationwide data at two-time points (2000 and 2012) to quantify the effects on CHD mortality attributable to changes in risk factors and therapeutic trends.

RESULTS

From 2000 to 2012, CHD mortality rates increased by 33.8% in men and by 22.8% in women. The IMPACT model explained 71% of the CHD mortality increase. Most of the mortality increases could be attributed to increases in population risk factors, such as diabetes (43%), physical inactivity (28%) and total cholesterol (24%). Improvements in medical and surgical treatments together prevented or postponed 40.3% of deaths; 10% was attributable to improvements in secondary prevention treatments following MI, while 5.3% to community heart failure treatments.

CONCLUSIONS

CHD mortality in Mexico is increasing due to adverse trends in major risk factors and suboptimal use of CHD treatments. Population-level interventions to reduce CHD risk factors are urgently needed, along with increased access and equitable distribution of therapies.

Decline of coronary heart disease mortality is strongly effected by changing patterns of underlying causes of death: an analysis of mortality data from 27 countries of the WHO European region 2000 and 2013

Mortality rates for coronary heart disease (CHD) experience a longstanding decline, attributed to progress in prevention, diagnostics and therapy. However, CHD mortality rates vary between countries. To estimate whether national patterns of causes of death impact CHD mortality, data from the WHO “European detailed mortality database” for 2000 and 2013 for populations aged ≥ 80 years was analyzed. We extracted mortality rates for total mortality, cardiovascular diseases, neoplasms, dementia and ill-defined causes. We calculated proportions of selected causes of death among all deaths, and proportions of selected cardiovascular causes among cardiovascular deaths. CHD mortality rates were recalculated after re-coding ill-defined causes of death. Association between CHD mortality rates and proportions of CHD deaths was estimated by population-weighted linear regression. National patterns of causes of death were divers. In 2000, CHD was assigned as cause of death in 13–53% of all cardiovascular deaths. Until 2013, this proportion changed between − 65% (Czech Republic) and + 57% (Georgia). Dementia was increasingly assigned as underlying cause of death in Western Europe, but rarely in eastern European countries. Ill-defined causes accounted for between < 1% and 53% of all cardiovascular deaths. CHD mortality rates were closely linked to a countries’ proportion of cardiovascular deaths assigned to CHD (R² = 0.95 for 2000 and 0.99 for 2013). We show that CHD mortality is considerably influenced by national particularities in certifying death. Changes in CHD mortality rates reflect changes in certifying competing underlying causes of death. This must be accounted for when discussing reasons for the CHD mortality decline.

Statins for the Primary Prevention of Coronary Heart Disease

Object

The purpose of this study was to fully assess the role of statins in the primary prevention of coronary heart disease (CHD).

Methods

We searched six databases (PubMed, the Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wanfang Database, and Chinese Scientific Journal Database) to identify relevant randomized controlled trials (RCTs) from inception to 31 October 2017. Two review authors independently assessed the methodological quality and analysed the data using Rev Man 5.3 software. Risk ratios and 95% confidence intervals (95% CI) were pooled using fixed/random-effects models. Funnel plots and Begg's test were conducted to assess publication bias. The quality of the evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

Results

Sixteen RCTs with 69159 participants were included in this review. Statins can effectively decrease the occurrence of angina (RR=0.70, 95% CI: 0.58~0.85, I² =0%), nonfatal myocardial infarction (MI) (RR=0.60, 95% CI: 0.51~0.69, I² =14%), fatal MI (RR=0.49, 95% CI: 0.24~0.98, I² =0%), any MI (RR=0.53, 95% CI: 0.42~0.67, I² =0%), any coronary heart events (RR=0.73, 95% CI: 0.68~0.78, I²=0%), coronary revascularization (RR=0.66, 95% CI: 0.55~0.78, I² = 0%), and any cardiovascular events (RR=0.77, 95% CI: 0.72~82, I² = 0%). However, based on the current evidence, there were no significant differences in CHD deaths (RR=0.82, 95% CI: 0.66~1.02, I²=0%) and all-cause mortality (RR=0.88, 95% CI: 0.76 ~1.01, I² =58%) between the two groups. Additionally, statins were more likely to result in diabetes (RR=1.21, 95% CI: 1.05~1.39, I² =0%). There was no evidence of publication biases, and the quality of the evidence was considered moderate.

Conclusion

Statins seemed to be beneficial for the primary prevention of CHDs but have no effect on CHD death and all-cause mortality.

Trends of case-fatality rate by acute coronary syndrome in Portugal: Impact of a fast track to the coronary unit

INTRODUCTION

Efforts were made to improve management of coronary disease as the fast-track system to the Coronary Unit. We aim to analyse case-fatality rates by acute coronary syndrome in Portugal from 2000 to 2016, mainly the impact of the fast-track system and the proportion of patients that activate the fast-track system.

METHODS

We analysed monthly acute coronary syndrome case-fatality before and after the implementation of the fast-track system in 2007. Impact of the system was assessed through regression models for interrupted time-series. We calculated annual proportion of fast-track system admissions.

RESULTS

After 2007 case-fatality by acute coronary syndrome decreased (β=-1.27, p-value < 0.01). The estimates obtained for ST Elevation Myocardial Infarction suggest a reduction of nearly 86 monthly deaths prevented after 2007. The highest percentage of patients admitted through the fast-track system was 35%.

CONCLUSIONS

Our results suggest fast-track system may have contributed to a decline in acute coronary syndrome case-fatality. However, more than half of patients were not admitted through the system. This should encourage health authorities to make efforts to ensure compliance.

Health-related knowledge on hypertension among the Portuguese population: results from a population-based survey

PURPOSE

Adequate knowledge on hypertension has been shown to improve awareness, adherence to treatment and control of the disease. We aimed to estimate the health-related knowledge about hypertension among the Portuguese population.

MATERIALS AND METHODS

A representative sample of Portuguese-speaking dwellers in mainland Portugal (n = 1624), aged 16 to 79 years, was evaluated through face-to-face interviews conducted using a structured questionnaire. Health literacy was evaluated using the instrument Newest Vital Sign.

RESULTS

The mean prevalence of hypertension in the Portuguese population estimated by the participants in this study was 45.4%. Salt intake and poor diet were reported as main causes of hypertension by 27.5% and 21.5% of the participants, respectively, whereas more than 85% acknowledged myocardial infarction and stroke as its main consequences. However, 31.2% of the participants were not able to identify a cause for high blood pressure, especially the older and those with worse scores for health literacy. The accurate interpretation of blood pressure values diminished with the increase of systolic and diastolic blood pressure figures provided as examples for interpretation, from approximately 80% for 95/60 mmHg to 50% for 180/100 mmHg. Women and participants with greater levels of education or a previous diagnosis of hypertension tended to interpret blood pressure values correctly more often.

CONCLUSIONS

This study provided a quantitative estimate of the gaps in health-related knowledge about hypertension among the general population. Understanding the barriers that hinder the achievement of health-related knowledge on hypertension is expected to contribute for the global improvement of prevention and management of hypertension.

Need for hyperlipidemia management policy reform in China: learning from the global experience

OBJECTIVE

To evaluate the hyperlipidemia prevention programs and policies in different countries and highlight the need of reforming the hyperlipidemia prevention policies in China to lower the growing cardiovascular disease (CVD) risk.

RESEARCH DESIGN AND METHODS

PubMed, Google Scholar and Cochrane were searched for global hyperlipidemia prevention policies. Government-funded policies pertaining to lipid management were considered for this review. Only those studies that evaluated the success of prevention policies on the basis of: (i) achievement of hyperlipidemia targets; (ii) improvement in Cardiovascular (CV) risk reduction; and (iii) outcomes with reduction in hyperlipidemia after implementation of the policy, were included.

RESULTS

Several global policies and programs aimed to improve CV health by highlighting lipid profile management. Implementation of the global and national policies led to improvement in cholesterol related outcomes such as availability of diagnostic measures, awareness of the risk factors, decrease in cholesterol levels, achieving healthy lifestyle to prevent CVD and improvement in availability of hypolipidemic medications, etc. Statins have been covered under reimbursement policies in many countries to improve usage and thereby preventing incidence of stroke and CVD. We observed a need for introducing new programs in China as the ongoing hyperlipidemia management policies are inadequate. The World Bank Report 2016 recommended that prevention policies in China be modeled on the US Million Hearts program.

CONCLUSIONS

New hyperlipidemia prevention policies must set a time-bound target, and need to be patient and clinician centric in terms of applications, and revised periodically for long-term benefits.

Sex-related inequalities in management of patients with acute coronary syndrome-results from the EURHOBOP study

BACKGROUND

Real-world data from different levels of hospital specialisation would help to understand if differences in management between women and men with acute coronary syndrome (ACS) are still a priority target. We aimed to identify sex inequalities in management of patients with different types of ACS.

METHODS

We analysed 1757 patients with a non-ST-elevation ACS (NSTEACS) and 1184 with ST elevation myocardial infarction (STEMI) or left bundle branch block (non-classifiable (NC) ACS (STEMI/NC ACS group), consecutively discharged from ten Portuguese hospitals with different specialisation levels, between 2008 and 2010. We estimated odds ratios (OR) and 95% confidence intervals (95% CI) for the association between sex and the performance of coronary angiography, reperfusion and revascularisation.

RESULTS

Among STEMI/NC ACS, men had higher probability of performing coronary angiography than women (adjusted OR = 1.64, 95% CI: 1.11-2.44), while among NSTEACS patients there was no significant difference by sex (adjusted OR = 1.26, 95% CI: 0.99-1.62). In patients who underwent coronary angiography, there was no difference in proportion of women and men submitted to revascularisation, regardless of the ACS type. Although men with STEMI/NC ACS were more likely to undergo reperfusion (crude OR = 2.17, 95% CI: 1.68-2.81), the effect became not significant after multivariable adjustment (adjusted OR = 1.33, 95% CI: 0.96-1.84).

CONCLUSION

Women diagnosed with STEMI/NC, but not NSTEACS, had lower probability when compared with men to be submitted to coronary angiography. There was no difference in performance of reperfusion and revascularisation by sex.

Clinical Profile and Management of Patients with Incident and Recurrent Acute Myocardial Infarction in Albania - a Call for More Focus on Prevention Strategies

Background

The clinical profile of acute myocardial infarction (AMI) patients reflects the burden of risk factors in the general population. Differences between incident (first) and recurrent (repeated) events and their impact on treatment are poorly described. We studied potential differences in the clinical profile and in-hospital treatment between patients hospitalised with an incident and recurrent AMI.

Methods

A total of 324 patients admitted in the Coronary Care Unit of ‘Mother Teresa’ hospital, Tirana, Albania (2013-2014), were included in the study. Information on AMI type, complications and risk factors was obtained from patient’s medical file.

Logistic regression analyses were used to explore differences between the incident and recurrent AMIs regarding clinical profile and in-hospital treatment.

Results

Of all patients, 50 (15.4%) had a prior AMI. Compared to incident cases, recurrent cases were older (P=0.01), more often women (P=0.01), less educated (P=0.01), and smoked less (P=0.03). Recurrent cases experienced more often heart failure (HF) (OR=2.48; 95% CI: 1.31–4.70), impaired left ventricular ejection fraction (OR=1.97; 95% CI:1.05–3.71), and multivessel disease (OR=6.32; 95% CI: 1.43–28.03) than incident cases. In-hospital use of beta-blockers was less frequent among recurrent compared to incident cases (OR=0.45; 95% CI: 0.24–0.85), while no statistically significant differences between groups were observed regarding angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, statin, aspirin or invasive procedures.

Conclusion

A more severe clinical expression of the disease and underutilisation of treatment among recurrent AMIs are likely to explain their poorer prognosis compared to incident AMIs.

A comparison of in-hospital acute myocardial infarction management between Portugal and the United States: 2000-2010

Objective

To compare healthcare in acute myocardial infarction (AMI) treatment between contrasting health systems using comparable representative data from Europe and USA.

Design

Repeated cross-sectional retrospective cohort study.

Setting

Acute care hospitals in Portugal and USA during 2000-2010.

Participants

Adults discharged with AMI.

Interventions

Coronary revascularizations procedures (percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG) surgery).

Main Outcome Measures

In-hospital mortality and length of stay.

Results

We identified 1 566 601 AMI hospitalizations. Relative to the USA, more hospitalizations in Portugal presented with elevated ST-segment, and fewer had documented comorbidities. Age-sex-adjusted AMI hospitalization rates decreased in USA but increased in Portugal. Crude procedure rates were generally lower in Portugal (PCI: 44% vs. 47%; CABG: 2% vs. 9%, 2010) but only CABG rates differed significantly after standardization. PCI use increased annually in both countries but CABG decreased only in the USA (USA: 0.95 [0.94, 0.95], Portugal: 1.04 [1.02, 1.07], odds ratios). Both countries observed annual decreases in risk-adjusted mortality (USA: 0.97 [0.965, 0.969]; Portugal: 0.99 [0.979, 0.991], hazard ratios). While between-hospital variability in procedure use was larger in USA, the risk of dying in a high relative to a low mortality hospital (hospitals in percentiles 95 and 5) was 2.65 in Portugal when in USA was only 1.03.

Conclusions

Although in-hospital mortality due to an AMI improved in both countries, patient management in USA seems more effective and alarming disparities in quality of care across hospitals are more likely to exist in Portugal.

The Atlantic divide in coronary heart disease: Epidemiology and patient care in the US and Portugal

INTRODUCTION AND OBJECTIVES

We aimed to compare access to new health technologies to treat coronary heart disease (CHD) in the health systems of Portugal and the US, characterizing the needs of the populations and the resources available.

METHODS

We reviewed data for 2000 and 2010 on epidemiologic profiles of CHD and on health care available to patients. Thirty health technologies (16 medical devices and 14 drugs) introduced during the period 1980-2015 were identified by interventional cardiologists. Approval and marketing dates were compared between countries.

RESULTS

Relative to the US, Portugal has lower risk profiles and less than half the hospitalizations per capita, but fewer centers per capita provide catheterization and cardiothoracic surgery services. More than 70% of drugs were available sooner in the US, whereas 12 out of 16 medical devices were approved earlier in Portugal. Nevertheless, at least five of these devices were adopted first or diffused faster in the US. Mortality due to CHD and myocardial infarction (MI) was lower in Portugal (CHD: 72.8 vs. 168 and MI: 48.7 vs. 54.1 in Portugal and the US, respectively; age- and gender-adjusted deaths per 100000 population, 2010); but only CHD deaths exhibited a statistically significant difference between the countries.

CONCLUSIONS

Differences in regulatory mechanisms and price regulations have a significant impact on the types of health technologies available in the two countries. However, other factors may influence their adoption and diffusion, and this appears to have a greater impact on mortality, due to acute conditions.

[Spanish adaptation of the 2016 European Guidelines on cardiovascular disease prevention in clinical practice]

The VI European Guidelines for Cardiovascular Prevention recommend combining population and high-risk strategies with lifestyle changes as a cornerstone of prevention, and propose the SCORE function to quantify cardiovascular risk. The guidelines highlight disease specific interventions, and conditions as women, young people and ethnic minorities. Screening for subclinical atherosclerosis with noninvasive imaging techniques is not recommended. The guidelines distinguish four risk levels (very high, high, moderate and low) with therapeutic objectives for lipid control according to risk. Diabetes mellitus confers a high risk, except for subjects with type 2 diabetes with less than <10 years of evolution, without other risk factors or complications, or type 1 diabetes of short evolution without complications. The decision to start pharmacological treatment of arterial hypertension will depend on the blood pressure level and the cardiovascular risk, taking into account the lesion of target organs. The guidelines don't recommend antiplatelet drugs in primary prevention because of the increased bleeding risk. The low adherence to the medication requires simplified therapeutic regimes and to identify and combat its causes. The guidelines highlight the responsibility of health professionals to take an active role in advocating evidence-based interventions at the population level, and propose effective interventions, at individual and population level, to promote a healthy diet, the practice of physical activity, the cessation of smoking and the protection against alcohol abuse.

Disability-adjusted life years lost due to ischemic heart disease in mainland Portugal, 2013

INTRODUCTION AND OBJECTIVES

Estimates of the burden of ischemic heart disease (IHD), including geographic differences, should support health policy decisions. We set out to estimate the burden of IHD in mainland Portugal in 2013 by calculating disability-adjusted life years (DALYs) and to compare this burden between five regions.

METHODS

Years of life lost (YLLs) were calculated by multiplying the number of IHD deaths in 2013 (Statistics Portugal) by the life expectancy at the age at which death occurred. Years lived with disability (YLDs) were computed as the number of cases of acute coronary syndrome, stable angina and ischemic heart failure multiplied by an average disability weight. Crude and age-standardized DALYs (direct method, Standard European Population) were calculated for mainland Portugal and for the Northern, Central, Lisbon, Alentejo and Algarve regions.

RESULTS

In 2013, 95413 DALYs were lost in mainland Portugal due to IHD. YLLs accounted for 88.3% of the disease burden. Age-standardized DALY rates per 1000 population were higher in men than in women, across the entire country (8.9 in men; 3.4 in women) and within each region, ranging from 7.3 in the Northern and Central regions to 11.8 in the Algarve in men, and from 2.6 in the Northern region to 4.6 in Lisbon in women.

CONCLUSIONS

Nearly 100000 DALYs were lost to IHD in Portugal, mostly through early mortality. This study enables accurate comparisons with other countries and between regions; however, it highlights the need for population-based studies to obtain specific data on morbidity.

[Spanish adaptation of the 2016 European Guidelines on cardiovascular disease prevention in clinical practice]

The VI European Guidelines for Cardiovascular Prevention recommend combining population and high-risk strategies with lifestyle changes as a cornerstone of prevention, and propose the SCORE function to quantify cardiovascular risk. The guidelines highlight disease specific interventions, and conditions as women, young people and ethnic minorities. Screening for subclinical atherosclerosis with noninvasive imaging techniques is not recommended. The guidelines distinguish four risk levels (very high, high, moderate and low) with therapeutic objectives for lipid control according to risk. Diabetes mellitus confers a high risk, except for subjects with type 2 diabetes with less than <10 years of evolution, without other risk factors or complications, or type 1 diabetes of short evolution without complications. The decision to start pharmacological treatment of arterial hypertension will depend on the blood pressure level and the cardiovascular risk, taking into account the lesion of target organs. The guidelines don't recommend antiplatelet drugs in primary prevention because of the increased bleeding risk. The low adherence to the medication requires simplified therapeutic regimes and to identify and combat its causes. The guidelines highlight the responsibility of health professionals to take an active role in advocating evidence-based interventions at the population level, and propose effective interventions, at individual and population level, to promote a healthy diet, the practice of physical activity, the cessation of smoking and the protection against alcohol abuse.

Spanish adaptation of the 2016 European Guidelines on cardiovascular disease prevention in clinical practice

The VI European Guidelines for Cardiovascular Prevention recommend combining population and high-risk strategies with lifestyle changes as a cornerstone of prevention, and propose the SCORE function to quantify cardiovascular risk. The guidelines highlight disease specific interventions, and conditions as women, young people and ethnic minorities. Screening for subclinical atherosclerosis with noninvasive imaging techniques is not recommended. The guidelines distinguish four risk levels (very high, high, moderate and low) with therapeutic objectives for lipid control according to risk. Diabetes mellitus confers a high risk, except for subjects with type 2 diabetes with less than <10 years of evolution, without other risk factors or complications, or type 1 diabetes of short evolution without complications. The decision to start pharmacological treatment of arterial hypertension will depend on the blood pressure level and the cardiovascular risk, taking into account the lesion of target organs. The guidelines don't recommend antiplatelet drugs in primary prevention because of the increased bleeding risk. The low adherence to the medication requires simplified therapeutic regimes and to identify and combat its causes. The guidelines highlight the responsibility of health professionals to take an active role in advocating evidence-based interventions at the population level, and propose effective interventions, at individual and population level, to promote a healthy diet, the practice of physical activity, the cessation of smoking and the protection against alcohol abuse.

Decline in Cardiovascular Mortality: Possible Causes and Implications

If the control of infectious diseases was the public health success story of the first half of the 20th century, then the decline in mortality from coronary heart disease and stroke has been the success story of the century's past 4 decades. The early phase of this decline in coronary heart disease and stroke was unexpected and controversial when first reported in the mid-1970s, having followed 60 years of gradual increase as the US population aged. However, in 1978, the participants in a conference convened by the National Heart, Lung, and Blood Institute concluded that a significant recent downtick in coronary heart disease and stroke mortality rates had definitely occurred, at least in the US Since 1978, a sharp decline in mortality rates from coronary heart disease and stroke has become unmistakable throughout the industrialized world, with age-adjusted mortality rates having declined to about one third of their 1960s baseline by 2000. Models have shown that this remarkable decline has been fueled by rapid progress in both prevention and treatment, including precipitous declines in cigarette smoking, improvements in hypertension treatment and control, widespread use of statins to lower circulating cholesterol levels, and the development and timely use of thrombolysis and stents in acute coronary syndrome to limit or prevent infarction. However, despite the huge growth in knowledge and advances in prevention and treatment, there remain many questions about this decline. In fact, there is evidence that the rate of decline may have abated and may even be showing early signs of reversal in some population groups. The National Heart, Lung, and Blood Institute, through a request for information, is soliciting input that could inform a follow-up conference on or near the 40th anniversary of the original landmark conference to further explore these trends in cardiovascular mortality in the context of what has come before and what may lie ahead.

[Spanish adaptation of the 2016 European Guidelines on cardiovascular disease prevention in clinical practice]

The VI European Guidelines for Cardiovascular Prevention recommend combining population and high-risk strategies with lifestyle changes as a cornerstone of prevention, and propose the SCORE function to quantify cardiovascular risk. The guidelines highlight disease specific interventions, and conditions as women, young people and ethnic minorities. Screening for subclinical atherosclerosis with noninvasive imaging techniques is not recommended. The guidelines distinguish four risk levels (very high, high, moderate and low) with therapeutic objectives for lipid control according to risk. Diabetes mellitus confers a high risk, except for subjects with type 2 diabetes with less than <10 years of evolution, without other risk factors or complications, or type 1 diabetes of short evolution without complications. The decision to start pharmacological treatment of arterial hypertension will depend on the blood pressure level and the cardiovascular risk, taking into account the lesion of target organs. The guidelines don't recommend antiplatelet drugs in primary prevention because of the increased bleeding risk. The low adherence to the medication requires simplified therapeutic regimes and to identify and combat its causes. The guidelines highlight the responsibility of health professionals to take an active role in advocating evidence-based interventions at the population level, and propose effective interventions, at individual and population level, to promote a healthy diet, the practice of physical activity, the cessation of smoking and the protection against alcohol abuse.

Explaining the Decline in Coronary Heart Disease Mortality in the Netherlands between 1997 and 2007

Objective

We set out to determine what proportion of the mortality decline from 1997 to 2007 in coronary heart disease (CHD) in the Netherlands could be attributed to advances in medical treatment and to improvements in population-wide cardiovascular risk factors.

Methods

We used the IMPACT-SEC model. Nationwide information was obtained on changes between 1997 and 2007 in the use of 42 treatments and in cardiovascular risk factor levels in adults, aged 25 or over. The primary outcome was the number of CHD deaths prevented or postponed.

Results

The age-standardized CHD mortality fell by 48% from 269 to 141 per 100.000, with remarkably similar relative declines across socioeconomic groups. This resulted in 11,200 fewer CHD deaths in 2007 than expected. The model was able to explain 72% of the mortality decline. Approximately 37% (95% CI: 10%-80%) of the decline was attributable to changes in acute phase and secondary prevention treatments: the largest contributions came from treating patients in the community with heart failure (11%) or chronic angina (9%). Approximately 36% (24%-67%) was attributable to decreases in risk factors: blood pressure (30%), total cholesterol levels (10%), smoking (5%) and physical inactivity (1%). Ten% more deaths could have been prevented if body mass index and diabetes would not have increased. Overall, these findings did not vary across socioeconomic groups, although within socioeconomic groups the contribution of risk factors differed.

Conclusion

CHD mortality has recently halved in The Netherlands. Equally large contributions have come from the increased use of acute and secondary prevention treatments and from improvements in population risk factors (including primary prevention treatments). Increases in obesity and diabetes represent a major challenge for future prevention policies.

Primary prevention and risk factor reduction in coronary heart disease mortality among working aged men and women in eastern Finland over 40 years: population based observational study

OBJECTIVE

To estimate how much changes in the main risk factors of cardiovascular disease (smoking prevalence, serum cholesterol, and systolic blood pressure) can explain the reduction in coronary heart disease mortality observed among working aged men and women in eastern Finland.

DESIGN

Population based observational study.

SETTING

Eastern Finland.

PARTICIPANTS

34,525 men and women aged 30-59 years who participated in the national FINRISK studies between 1972 and 2012.

INTERVENTIONS

Change in main cardiovascular risk factors through population based primary prevention.

MAIN OUTCOME MEASURES

Predicted and observed age standardised mortality due to coronary heart disease. Predicted change was estimated with a logistic regression model using risk factor data collected in nine consecutive, population based, risk factor surveys conducted every five years since 1972. Data on observed mortality were obtained from the National Causes of Death Register.

RESULTS

During the 40 year study period, levels of the three major cardiovascular risk factors decreased except for a small increase in serum cholesterol levels between 2007 and 2012. From years 1969-1972 to 2012, coronary heart disease mortality decreased by 82% (from 643 to 118 deaths per 100,000 people) and 84% (114 to 17) among men and women aged 35-64 years, respectively. During the first 10 years of the study, changes in these three target risk factors contributed to nearly all of the observed mortality reduction. Since the mid-1980s, the observed reduction in mortality has been larger than predicted. In the last 10 years of the study, about two thirds (69% in men and 66% in women) of the reduction could be explained by changes in the three main risk factors, and the remaining third by other factors.

CONCLUSION

Reductions in disease burden and mortality due to coronary heart disease can be achieved through the use of population based primary prevention programmes. Secondary prevention among high risk individuals and treatment of acute events of coronary heart disease could confer additional benefit.

Effectiveness of an early versus a conservative invasive treatment strategy in acute coronary syndromes: a nationwide cohort study

BACKGROUND

Randomized clinical trials have found that early invasive strategies reduce mortality, myocardial infarction (MI), and rehospitalization compared with a conservative invasive approach in acute coronary syndromes (ACSs), but the effectiveness of such strategies in real-world settings is unknown.

OBJECTIVE

To investigate adverse cardiovascular outcomes of an early versus a conservative invasive strategy in a national cohort of patients with ACSs.

DESIGN

Retrospective cohort study.

SETTING

Administrative health care data on hospitalizations, procedures, and outcomes abstracted from the Danish national registries and covering all acute invasive procedures in patients presenting with an ACS.

PATIENTS

19 704 propensity score-matched patients hospitalized with a first ACS between 1 January 2005 and 31 December 2011.

MEASUREMENTS

Risk for cardiac death or rehospitalization for MI within 60 days of hospitalization.

RESULTS

Compared with a conservative approach, early invasive strategies were associated with a lower risk for cardiac death (cumulative incidence, 5.9% vs. 7.6%; adjusted hazard ratio [HR], 0.75 [95% CI, 0.66 to 0.84]; P < 0.001). Similar results were found for rehospitalization for MI (cumulative incidence, 3.4% vs. 5.0%; adjusted odds ratio, 0.67 [CI, 0.58 to 0.77]; P < 0.001) and all-cause death (cumulative incidence, 7.3% vs. 10.6%; adjusted HR, 0.65 [CI, 0.59 to 0.72]; P < 0.001).

LIMITATION

Potential residual confounding due to lack of core clinical variables.

CONCLUSION

In this real-world cohort of patients with a first hospitalization for an ACS, the use of an early invasive treatment strategy was associated with a lower risk for cardiac death and rehospitalization for MI compared with a conservative invasive approach.

PRIMARY FUNDING SOURCE

Department of Cardiology, University Hospital Gentofte.