Analysis of acute COVID-19 including chronic morbidity: protocol for the deep phenotyping National Pandemic Cohort Network in Germany (NAPKON-HAP)

BACKGROUND

The severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) pandemic causes a high burden of acute and long-term morbidity and mortality worldwide despite global efforts in containment, prophylaxis, and therapy. With unprecedented speed, the global scientific community has generated pivotal insights into the pathogen and the host response evoked by the infection. However, deeper characterization of the pathophysiology and pathology remains a high priority to reduce morbidity and mortality of coronavirus disease 2019 (COVID-19).

METHODS

NAPKON-HAP is a multi-centered prospective observational study with a long-term follow-up phase of up to 36 months post-SARS-CoV-2 infection. It constitutes a central platform for harmonized data and biospecimen for interdisciplinary characterization of acute SARS-CoV-2 infection and long-term outcomes of diverging disease severities of hospitalized patients.

RESULTS

Primary outcome measures include clinical scores and quality of life assessment captured during hospitalization and at outpatient follow-up visits to assess acute and chronic morbidity. Secondary measures include results of biomolecular and immunological investigations and assessment of organ-specific involvement during and post-COVID-19 infection. NAPKON-HAP constitutes a national platform to provide accessibility and usability of the comprehensive data and biospecimen collection to global research.

CONCLUSION

NAPKON-HAP establishes a platform with standardized high-resolution data and biospecimen collection of hospitalized COVID-19 patients of different disease severities in Germany. With this study, we will add significant scientific insights and provide high-quality data to aid researchers to investigate COVID-19 pathophysiology, pathology, and chronic morbidity.

Medical graphics to improve patient understanding and anxiety in elderly and cognitively impaired patients scheduled for transcatheter aortic valve implantation (TAVI)

BACKGROUND

Anxiety and limited patient comprehension may pose significant barriers when informing elderly patients about complex procedures such as transcatheter aortic valve implantation (TAVI).

OBJECTIVES

We aimed to evaluate the utility of medical graphics to improve the patient informed consent (IC) before TAVI.

METHODS

In this prospective, randomized dual center study, 301 patients were assigned to a patient brochure containing medical graphics (Comic group, n = 153) or sham information (Control group, n = 148) on top of usual IC. Primary outcomes were patient understanding of central IC-related aspects and periprocedural anxiety assessed by the validated Spielberger State Trait Anxiety Inventory (STAI), both analyzed by cognitive status according to the Montreal Cognitive Assessment (MoCA).

RESULTS

Patient understanding was significantly higher in the Comic group [mean number of correct answers 12.8 (SD 1.2) vs. 11.3 (1.8); mean difference 1.5 (95% CI 1.2-1.8); p < 0.001]. This effect was more pronounced in the presence of cognitive dysfunction (MoCA < 26) [12.6 (1.2) in the Comic vs. 10.9 (1.6) in the Control group; mean difference 1.8 (1.4-2.2), p < 0.001]. Mean STAI score declined by 5.7 (95% CI 5.1-6.3; p < 0.001) in the Comic and 0.8 points (0.2-1.4; p = 0.015) in the Control group. Finally, mean STAI score decreased in the Comic group by 4.7 (3.8-5.6) in cognitively impaired patients and by 6.6 (95% CI 5.8 to 7.5) in patients with normal cognitive function (p < 0.001 each).

CONCLUSIONS

Our results prove beneficial effects for using medical graphics to inform elderly patients about TAVI by improving patient understanding and reducing periprocedural anxiety (DRKS00021661; 23/Oct/2020). Medical graphics entailed significant beneficial effects on the primary endpoints, patient understanding and periprocedural anxiety, compared to the usual patient informed consent (IC) procedure. Patient understanding of IC-related aspects was significantly higher in the Comic group, with a more pronounced benefit in patients with cognitive impairment (p for IC method and cognitive status < 0.001, respectively; p for IC method x MoCA category interaction = 0.017). There further was a significant decline of periprocedural anxiety in patients with and without cognitive impairment (p for IC method x measuring time point < 0.001; p for IC method x MoCA category x measuring time point interaction = 0.018).

Clinical and Procedural Outcomes of IVUS-Guided vs. Angiography-Guided CTO-PCI: A Systematic Review and Meta-Analysis

Chronic total occlusions (CTO) in coronary angiographies present a significant challenge nowadays. Intravascular ultrasound (IVUS) is a valuable tool during CTO-PCI, aiding in planning and achieving procedural success. However, the impact of IVUS on clinical and procedural outcomes in CTO-PCI remains uncertain. This meta-analysis aimed to compare IVUS-guided and angiography-guided approaches in CTO-PCI. The study included five studies and 2320 patients with stable coronary artery disease (CAD) and CTO. The primary outcome of major adverse cardiac events (MACE) did not significantly differ between the groups (p = 0.40). Stent thrombosis was the only secondary clinical outcome that showed a significant difference, favoring the IVUS-guided approach (p = 0.01). Procedural outcomes revealed that IVUS-guided procedures had longer stents, larger diameters, and longer procedure and fluoroscopy times (p = 0.007, p < 0.001, p = 0.03, p = 0.002, respectively). Stent number and contrast volume did not significantly differ between the approaches (p = 0.88 and p = 0.33, respectively). In summary, routine IVUS use did not significantly improve clinical outcomes, except for reducing stent thrombosis. Decisions in CTO-PCI should be individualized based on patient characteristics and supported by a multi-parametric approach.

Cardiogenic Shock Management and Research: Past, Present, and Future Outlook

Although great strides have been made in the pathophysiological understanding, diagnosis and management of cardiogenic shock (CS), morbidity and mortality in patients presenting with the condition remain high. Acute MI is the commonest cause of CS; consequently, most existing literature concerns MI-associated CS. However, there are many more phenotypes of patients with acute heart failure. Medical treatment and mechanical circulatory support are well-established therapeutic options, but evidence for many current treatment regimens is limited. The issue is further complicated by the fact that implementing adequately powered, randomized controlled trials are challenging for many reasons. In this review, the authors discuss the history, landmark trials, current topics of medical therapy and mechanical circulatory support regimens, and future perspectives of CS management.

Immune Mechanisms of Plaque Instability

Inflammation crucially drives atherosclerosis from disease initiation to the emergence of clinical complications. Targeting pivotal inflammatory pathways without compromising the host defense could compliment therapy with lipid-lowering agents, anti-hypertensive treatment, and lifestyle interventions to address the substantial residual cardiovascular risk that remains beyond classical risk factor control. Detailed understanding of the intricate immune mechanisms that propel plaque instability and disruption is indispensable for the development of novel therapeutic concepts. In this review, we provide an overview on the role of key immune cells in plaque inception and progression, and discuss recently identified maladaptive immune phenomena that contribute to plaque destabilization, including epigenetically programmed trained immunity in myeloid cells, pathogenic conversion of autoreactive regulatory T-cells and expansion of altered leukocytes due to clonal hematopoiesis. From a more global perspective, the article discusses how systemic crises such as acute mental stress or infection abruptly raise plaque vulnerability and summarizes recent advances in understanding the increased cardiovascular risk associated with COVID-19 disease. Stepping outside the box, we highlight the role of gut dysbiosis in atherosclerosis progression and plaque vulnerability. The emerging differential role of the immune system in plaque rupture and plaque erosion as well as the limitations of animal models in studying plaque disruption are reviewed.

Assessment of stent optimization in clinical practice using optical coherence tomography: a multicentric observational study

Background

Stent under-expansion obtained at the time of percutaneous coronary intervention (PCI) has been shown to be associated with worse outcomes.

Purpose

We sought to define OCT assessed optimal stent expansion index which associates with lower incidence of major adverse cardiac events (MACE) during follow-up in a sample of patients stented at five high volume centers of central Europe.

Methods

We analyzed 370 lesions stented during the period between 2012 and 2018, with their final procedural results imaged using optical coherence tomography (OCT). QIvus Research Edition v3.1 (Medis, Leiden, NL) was used for OCT analysis. The stented segment was split in two equal halves. Stent expansion index (SEI) was calculated for both halves separately by dividing minimum stent area by the mean reference lumen area [(proximal reference area + distal reference area)/2]. Smallest of the two prevailed as the SEI of that case. MACE during post-PCI follow-up was defined as composite of all-cause death, myocardial infarction, stent thrombosis and target lesion revascularization. Data is expressed as mean±SD or median (Interquartile range). Incidence of subsequent MACE is expressed as crude rates (%).

Results

A total of 316 cases (370 lesions), aged 64.6±11.7 years were included for OCT analysis. Of them, 78.8% were males, 22.8% were diabetics, 75.9% were hypertensives while 35.1% had family history of coronary artery disease. 38.0% of the cases had acute coronary syndrome at presentation. 62.4% of treated lesions were complex (Type B2/C). A mean of 1.11±0.34 stents/scaffolds were implanted per treated lesion. Analyzed segment length was 20.4 (15.17, 27.0) mm.

Minimal stent area (MSA) in the overall stented segment was 6.02 mm2 (4.65, 7.93). Median stent expansion index (minimum) was 0.79 (0.71, 0.86). Median follow-up duration was 557 days (326, 1,096). 47 lesions (12.7%) suffered MACE during follow-up. Receiver operating characteristic (ROC) curve analysis using Youden's rule identified 0.84 as SEI cut-off powered to predict post-PCI MACE (AUC= 0.60, sensitivity= 0.85, specificity= 0.34). MACE was observed in 38/249 (15.3%) of lesions with SEI≤0.84 and in 9/121 (7.4%) of lesions with SEI&gt;0.84 (p=0.03). Univariate regression analysis of MACE revealed significant association with SEI≤0.84 (OR=2.2, 95% CI=1.1–4.8, p=0.04) Adaptive Lasso regression identified SEI≤0.84 (OR=4.1, 95% CI=1.3–12.6, p=0.02) and coronary calcification at baseline (OR=2.7, 95% CI=1.1–6.6, p=0.03) as independent predictors of MACE during follow-up. Kaplan-meier curve for MACE free survival with optimal SEI (n=121) and sub-optimal SEI (n=249) subgroups using SEI cut-off of 0.84, however showed modest separation (p=0.11).

Conclusions

The present study identified SEI&gt;0.84 associated with lower incidence of MACE as optimal cut-off in daily practice. Along with SEI of ≤0.84, coronary calcification was also significantly associated with MACE during post PCI follow-up.

Funding Acknowledgement

Type of funding sources: None.

The role of cardiologists on the stroke unit

Cardiologists need a better understanding of stroke and of cardiac implications in modern stroke management. Stroke is a leading disease in terms of mortality and disability in our society. Up to half of ischaemic strokes are directly related to cardiac and large artery diseases and cardiovascular risk factors are involved in most other strokes. Moreover, in an acute stroke direct central brain signals and a consecutive autonomic/vegetative imbalance may account for severe and life-threatening cardiovascular complications. The strong cerebro-cardiac link in acute stroke has recently been addressed as the stroke-heart syndrome that requires careful cardiovascular monitoring and immediate therapeutic measures. The regular involvement of cardiologic expertise in daily work on a stroke unit is therefore of high importance and a cornerstone of up-to-date comprehensive stroke care concepts. The main targets of the cardiologists' contribution to acute stroke care can be categorized in three main areas (i) diagnostics workup of stroke aetiology, (ii) treatment and prevention of complications, and (iii) secondary prevention and sub-acute workup of cardiovascular comorbidity. All three aspects are by themselves highly relevant to support optimal acute management and to improve the short-term and long-term outcomes of patients. In this article, an overview is provided on these main targets of cardiologists' contribution to acute stroke management.

Impact of oral anticoagulation on clinical outcomes of COVID-19: a nationwide cohort study of hospitalized patients in Germany

Objectives

The aim of this study was to investigate the impact of concomitant long-term medication—with a focus on ACE inhibitors and oral anticoagulation—on clinical outcomes in patients hospitalized with coronavirus disease 2019.

Methods

This is a retrospective cohort study using claims data of the biggest German health insurance company AOK, covering 26.9 million people all over Germany. In particular, patient-related characteristics and co-medication were evaluated. A multivariable logistic regression model was adopted to identify independent predictors for the primary outcome measure of all-cause mortality or need for invasive or non-invasive ventilation or extracorporeal membrane oxygenation.

Results

6637 patients in 853 German hospitals were included. The primary outcome occurred in 1826 patients (27.5%). 1372 patients (20.7%) died, 886 patients (13.3%) needed respiratory support, and 53 patients (0.8%) received extracorporeal membrane oxygenation. 34 of these patients survived (64.2%). The multivariable model demonstrated that pre-existing oral anticoagulation therapy with either vitamin-K antagonists OR 0.57 (95% CI 0.40–0.83, p = 0.003) or direct oral anticoagulants OR 0.71 (95% CI 0.56–0.91, p = 0.007)—but not with antiplatelet therapy alone OR 1.10 (95% CI 0.88–1.23, p = 0.66)—was associated with a lower event rate. This finding was confirmed in a propensity match analysis.

Conclusions

In a multivariable analysis, a therapy with both direct oral anticoagulants or vitamin-K antagonists—but not with antiplatelet therapy—was associated with improved clinical outcomes. ACE inhibitors did not impact outcomes. Prospective randomized trials are needed to verify this hypothesis.

Graphic abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00392-020-01783-x.

5938Mortality risk stratification in patients with severe tricuspid regurgitation - Insights from the Tricuspid Regurgitation REgistry (TRuE)

Background/Introduction

Severe tricuspid regurgitation (TR) is associated with progressive right atrial (RA) and ventricular (RV) dilation, dysfunction and increased mortality. Risk factors impacting the long-term prognosis in patients with severe TR are largely undetermined.

Purpose

Herein, we aimed to identify risk factors associated with long-term mortality in patients with severe TR and implement a novel risk stratification strategy based on an individual five-year mortality prediction score.

Methods

From January 2013 to December 2017, 1238 patients with severe functional TR were enrolled in the TRuE-registry, of which 914 with a complete dataset were included in the present study. Echocardiographic quantification of RV-function and size included measurements of tricuspid annular plane systolic excursion (TAPSE), the end-diastolic basal (RVDbasal) and longitudinal diameters (RVDlong) and the RA-volume index (RAVI). The cohort was randomly divided into a development (n=610) and validation (n=304) sample. A risk stratification model was developed using a multivariable Cox regression.

Results

The variables statistically significant to predict five-year-mortality, included in the final model and used as score parameters were: age, COPD, dialysis, pulmonary artery systolic pressure, RAVI, TAPSE RVDbasal, RVDlong and systolic hepatic vein flow reversal (sHVFR). Progressive enlargement of RV and RA and concomitant sHVFR was associated with higher values of hazard ratios (HR, Figure A). Based on the HR values, a risk score with 3 categories was developed (Figure B): low (0–2), intermediate (3–5), high (6–16). Among the risk groups, Kaplan Meier estimates of all-cause mortality at 5 years were 18%, 52% and 84% respectively (p<0.001; https://thetruerisk.com). The score showed good discrimination, with a concordance index of 0.75. At internal validation, a good agreement between the derivation and validation datasets indicated a good calibration of the survival curves.

Implementation of a long term risk score

Conclusion

The present study demonstrates the prognostic impact of comorbidities and right heart remodeling on long-term mortality in patients with severe TR. The presented risk score provides an easy and accurate estimation of long-term mortality and may thus help to guide therapeutic decision-making in this difficult group of patients.

54Role of the gut microbiome for the cholesterol lowering effect of atorvastatin

Background and aims

Statins show interindividual differences in the extent of low-density lipoprotein cholesterol (LDL-C) reduction. The mechanisms of this interindividual variation are not fully understood. Here, we examined the potential role of the gut microbiome for the LDL-C lowering property of atorvastatin.

Methods

Mice (C57BL/6) with either intact (conventional mice, CONV, n=24) or with antiobiotic depleted gut microbiome (gnotobiotic, n=16), were put on standard chow diet (SCD) (n=11) or high fat diet (HFD) (n=29) for 6 weeks. During the last 4 weeks atorvastatin (Ator, 10mg/kg body weight/day) or control vehicle was orally applied via gavage. Blood levels of LDL-C and glucose and body weight after 6 weeks of treatment were compared between the groups. Expression of genes involved in hepatic and intestinal cholesterol-metabolism were examined. Faeces of CONV mice were analyzed for alteration of the gut microbiota profile upon atorvastatin treatment using 16S rRNA qPCR.

Results

HFD fed mice with intact gut microbiome showed significantly increased blood LDL-C levels as compared to SCD (HFD: 36.8±1.4 mg/dl vs. SCD: 22.0±1.8 mg/dl; P<0.01). Bodyweight gain or blood glucose levels after HFD were not significantly different between CONV and gnotobiotic mice. While in CONV mice atorvastatin significantly reduced LDL-C levels after HFD, in gnotobiotic mice the LDL-C lowering effect of atorvastatin was attenuated (CONV+HFD+Ator: 31.0±1.8 mg/dl vs. gnotobiotic mice+HFD+Ator: 46.4±3 mg/dl; P<0.01). The expression of genes involved in hepatic cholesterol synthesis was not significantly altered in gnotobiotic mice as compared to CONV mice. In CONV mice HFD decreased the relative abundance of the bacterial phyla Bacteroidetes and increased the abundance of Firmicutes as compared to SCD. The ratio between Firmicutes to Bacteroidetes was shifted towards control conditions upon atorvastatin treatment.

Conclusions

The results of this study suggest a regulatory impact of atorvastatin on the gut-microbial profile and, in turn, a crucial role of the gut-microbiome for the LDL-C lowering effect of atorvastatin independent of its regulation of hepatic cholesterol synthesis. Our findings provide novel insight into potential microbiota-related mechanisms causing interindividual variation in LDL-C lowering effects of statins.

Acknowledgement/Funding

German Heart Research Foundation

Effect on Outcomes: Infections Complicating Percutaneous Coronary Interventions in Patients ≥80 Years of Age

Data on the prevalence of infections in patients who underwent percutaneous coronary intervention (PCI) and their impact on outcomes are scarce. In this study, a total of 644 patients ≥80 years of age who underwent PCI were stratified according to the presence/absence of infections requiring antibiotic therapy. The primary end point was major adverse cardiovascular events (MACE) after discharge, a composite of all-cause mortality, nonfatal myocardial infarction, and rehospitalization for heart failure. Median follow-up was 1.2 (interquartile range 0.1 to 3.4) years. Of the 644 patients, 186 (28.9%) had infections during index hospitalization, with 84 (13%) and 59 (9.2%) patients having pneumonia and urinary tract infections, respectively. Patients with infections were older, more often women, and had an increased prevalence of atrial fibrillation and congestive heart failure. Infections prolonged hospital stay (10 [7 to 16] vs 5 [3 to 7] days, p <0.001), but were not related to rates of MACE (20% vs 19%, adjusted hazard ratio [HR] 1.41, 95% confidence intervals 0.84 to 2.38, p = 0.20). Pneumonia was significantly associated with increased rates of MACE (27% vs 18%, adjusted HR 2.19, 95% confidence intervals 1.23 to 3.91, p = 0.008) and rehospitalization for heart failure (17% vs 10%, adjusted HR 2.66 (1.25 to 5.63, p = 0.01), whereas urinary tract infections were not. In conclusion, concomitant infections are frequent in patients ≥80 years of age who underwent PCI, and associated with an increased risk of adverse events when affecting the respiratory system.

Left atrial appendage angiography is associated with the incidence and number of magnetic resonance imaging-detected brain lesions after percutaneous catheter-based left atrial appendage closure

BACKGROUND

Percutaneous catheter-based left atrial appendage closure (LAAC) is a procedure being increasingly performed in patients with atrial fibrillation and high bleeding risk.

OBJECTIVE

The purpose of this study was to evaluate the incidence of magnetic resonance imaging (MRI)-detected acute brain lesions (ABLs) as well as potential changes in neurocognitive function after percutaneous LAAC in patients with atrial fibrillation.

METHODS

Brain MRI at 3 T was performed within 24 hours before and after LAAC along with neurologic (National Institutes of Health Stroke Scale [NIHSS] score) and cognitive (Montreal Cognitive Assessment [MoCA] test) assessment. Acquired MRI sequences included high-resolution diffusion-weighted imaging as well as fluid-attenuated inversion recovery.

RESULTS

Successful device implantation was achieved in all 23 patients (age 74.1 ± 10.5 years; 16 male) using the Amulet (n = 18), Occlutech (n = 3), or LAmbre (n = 2) device. Thirty-seven ABLs were detected by MRI in 12 of 23 patients (52%) after LAAC. The number of periprocedural LAA angiographies was significantly higher in patients with ABL than in those without ABL (1.67 ± 0.65 vs 1.18 ± 0.41; P = .048) and was associated with a higher number of ABL (ρ = 0.615; P = .033). Compared to pre-LAAC assessment, post-LAAC MoCA and NIHSS scores revealed similar results. After LAAC, MoCA test (mean 24.1 ± 4.6 vs 23.2 ± 4.6; P = .09) and NIHSS score (mean 1.0 ± 1.7 vs 1.2 ± 1.8; P = .1) were similar between patients with and those without ABL, respectively.

CONCLUSION

MRI-detected ABLs are commonly observed after percutaneous LAAC. The number of LAA angiographies is significantly associated with the number of ABLs; however, the clinical implications of ABL have yet to be determined.

[Catheter-based atrial appendage closure-current data and future developments]

In Germany more than 1.6 million patients suffer from atrial fibrillation (AF). Within the next decades this number will substantially increase due to current demographic trends with the increasing average age of the population. When untreated, patients with atrial fibrillation have a five times higher risk for stroke as compared with a control cohort. A potent stroke prevention therapy reducing the risk of stroke by approximately 70-80% is primarily treatment with new oral anticoagulants (NOACs). The risk scores for stroke (CHA₂DS₂-VASc) and major bleeding (HAS-BLED) in patients with atrial fibrillation share common variables, so that patients with the highest stroke risk often carry a very high bleeding risk. A significant number of patients (ca. 20-30%) are, however, not eligible for long-term anticoagulation, e.g. because of a high bleeding risk. For this population there is an urgent need for alternative stroke prevention strategies, such as catheter-based percutaneous left atrial appendage closure. Current data about the efficiency and safety of this treatment as well as a discussion of ongoing recruitment for randomized studies are discussed in this review.

Long-term follow up of 3 T MRI-detected brain lesions after percutaneous catheter-based left atrial appendage closure

BACKGROUND

Left atrial appendage closure (LAAC) for stroke prevention is an increasingly performed intervention.

AIMS

This prospective study aims to evaluate the incidence of long-term magnetic resonance imaging (MRI)-detected brain lesions as well as potential changes of neurocognitive function after percutaneous LAAC.

METHODS

Brain MRI at 3 T was performed within 24 hr before and after LAAC. A follow-up MRI was carried out after three months. Neuro-cognitive examination using the National Institutes of Health Stroke Scale (NIHSS) score and the Montreal Cognitive Assessment (MoCA) Test was performed.

RESULTS

Successful device implantation was achieved in all 25 patients (age 74.6 ± 10.2 years, male = 17) using the Amulet (n = 20), Occlutech (n = 3), or a Lambre (n = 2) device. In 12/25 (48%) patients, acute brain lesions (ABL) were detected after LAAC. A three-month follow-up MRI was performed in seven patients, and no new ABLs were seen. In 5/7 (71%) patients, there were no residual changes from the ABLs detectable. However, the FLAIR sequence was still positive in two patients. After LAAC, there were no significant differences in the MoCA-test (mean 24.3 ± 4.5 vs. 23.5 ± 4.5; P = 0.1) and the NIHSS-score (mean 0.9 ± 1.6 vs. 1.2 ± 1.8; P = 0.1). This was the same at the three-month follow-up (MoCA-test 23.5 ± 4.5 vs. 23.8 ± 2.7; P = 0.3; NIHSS-score 1.2 ± 1.8 vs. 1.0 ± 0.8; P = 0.4).

CONCLUSION

While new MRI-detected brain lesions are commonly observed after percutaneous LAAC, ABLs were no longer detectable in 71% of the patients at the three-month follow-up. There were no significant changes in neurocognitive function after LAAC and at the three-month follow-up.

The DETECT adherence score--structure and psychometric exploration of a novel approach to measure adherence to drug and non-drug interventions in primary care

There is substantial evidence that patient compliance or rather adherence to medical measures and recommendations for lifestyle changes can pivotally influence the prognosis of the patients or disease progression. However, the scientific evaluation and the statistical analysis of "patient adherence" are extremely difficult due to the fact that the construct of "adherence" is complex and comprised of many layers, and varies greatly in different disease groups. With this paper, we describe the development and structure of this novel assessment tool that takes past and prospective information on different facets of drug and behavioural adherence into account, expected to result in considerably improved prediction of future cardiovascular risk. We suggest a simple scoring scheme and explore the psychometric properties and the higher order factorial structure. In this exploratory study the "Diabetes Cardiovascular Risk Evaluation Targets and Essential Data for Commitment of Treatment" (DETECT) adherence score revealed good psychometric properties in terms of internal consistency and factorial structure, suggesting that its further exploration in terms of external validity is promising. Findings also underline that it is useful and informative to cover within one score both, pharmacologic and non-pharmacologic interventions in primary care. Our combination in this respect is unique, as most studies conducted on this subject so far aimed at assessing solely drug adherence or behavioural adherence.