P3397Risk Or Benefit IN Screening for CArdiovascular disease (ROBINSCA): results from screening for a high cardiovascular disease risk by using a risk prediction model or coronary artery calcium scoring

Introduction

The ROBINSCA (Risk Or Benefit IN Screening for CArdiovascular disease) trial is a large-scale population-based randomized controlled screening trial with the aim to investigate whether screening for a high risk of cardiovascular disease (CVD) by means of either the Systematic COronary Risk Evaluation (SCORE) model or coronary artery calcium (CAC) scoring followed by preventive treatment is effective in reducing morbidity and mortality from coronary heart disease (CHD). This study shows the results of the CVD risks as assessed by the two screening tools.

Methods

Based on the Dutch population registry, 394,058 men aged 45–74 years and women aged 55–74 years received an information brochure, an invitation to participate in the trial, a baseline questionnaire with waist circumference tape and an informed consent form. Eligible individuals with an expected high CVD risk were randomized (1:1:1) into a control arm (n=14,519), intervention arm A (n=14,478) or intervention arm B (n=14,450). In the control arm, usual care was continued. In intervention arm A, participants were screened for a high risk of CVD using the SCORE model based on traditional risk factors. In intervention arm B, CAC scoring after computed tomography scanning was used for screening. After screening en risk communication, preventive treatment according to the Dutch guidelines is advised for high risk persons.

Results

Screening uptake was 84.2% in intervention arm A and 89.6% in intervention arm B. Of the screened participants, 48.7% was female, median age at screening was 62 (Interquartile Range 10), 35.2% was high educated, 19.6% was baseline smoker and 41.4% had a positive family history of myocardial infarction. The assessed CVD risk status according to SCORE screening was stratified into three risk categories; 45.1% was at low risk (SCORE<10%), 26.5% was at intermediate risk (SCORE 10–20%), and 28.4% was at high risk (SCORE ≥20%). According to CAC screening, 76.0% was at low risk (Agatston <100), 15.1% was at high risk (Agatston 100–399), and 8.9% was at very high risk (Agatston ≥400). Associations between baseline variables and increased CVD risk will be analyzed soon and will be available in summer 2019.

Conclusions

Using different screening tools resulted in reclassification of the CVD risk. CAC screening caused a substantial shift to more low risk individuals. This might, when screening is found to be effective, lead to less overtreatment in prevention of CVD events. Future 5-year follow-up data should provide evidence about whether population-based screening with subsequent preventive treatment is (cost-)effective in reducing CHD-related morbidity and mortality.

Comparison of randomization techniques for clinical trials with data from the HOMERUS‐trial

BACKGROUND

Several methods of randomization are available to create comparable intervention groups in a study. In the HOMERUS-trial, we compared the minimization procedure with a stratified and a non-stratified method of randomization in order to test which one is most appropriate for use in clinical hypertension trials. A second objective of this article was to describe the baseline characteristics of the HOMERUS-trial.

METHODS

The HOMERUS population consisted of 459 mild-to-moderate hypertensive subjects (54% males) with a mean age of 55 years. These patients were prospectively randomized with the minimization method to either the office pressure (OP) group, where antihypertensive treatment was based on office blood pressure (BP) values, or to the self-pressure (SP) group, where treatment was based on self-measured BP values. Minimization was compared with two other randomization methods, which were performed post-hoc: (i) non-stratified randomization with four permuted blocks, and (ii) stratified randomization with four permuted blocks and 16 strata. In addition, several factors that could influence outcome were investigated for their effect on BP by 24-h ambulatory blood pressure monitoring (ABPM).

RESULTS

Minimization and stratified randomization did not lead to significant differences in 24-h ABPM values between the two treatment groups. Non-stratified randomization resulted in a significant difference in 24-h diastolic ABPM between the groups. Factors that caused significant differences in 24-h ABPM values were: region, centre of patient recruitment, age, gender, microalbuminuria, left ventricular hypertrophy and obesity.

CONCLUSION

Minimization and stratified randomization are appropriate methods for use in clinical trials. Many outcome factors should be taken into account for their potential influence on BP levels. Recommendation. Due to the large number of potential outcome factors that can influence BP levels, minimization should be the preferred method for use in clinical hypertension trials, as it has the potential to randomize more outcome factors than stratified randomization.

Reversal of pathophysiologic changes with long-term lisinopril treatment in isolated systolic hypertension

The purpose of this study was to evaluate in a prospective, double-blind, placebo-controlled study the effect of long-term (2-year) lisinopril treatment on cardiovascular end-organ damage in patients with previously untreated isolated systolic hypertension (ISH). All patients with ISH were derived from a population screening program. End-organ damage measurements, done initially and after 6 and 24 months of treatment, included measurements of aortic distensibility and echocardiographic left ventricular mass index (LVMI) and diastolic function. Blood pressure was measured by office and ambulatory measurements. Of the 97 subjects with ISH selected from the screening, 62 (30 lisinopril) completed the study according to protocol. Office blood pressure decreased in both groups, but ambulatory results significantly decreased with lisinopril-treatment only. Aortic distensibility increased significantly with lisinopril, as opposed to a decrease in placebo-treated subjects. The main effect of increased distensibility occurred between 6 and 24 months, whereas ambulatory blood pressure changed mainly in the first 6 months of treatment. LVMI decreased in both treatment groups, with a significantly higher reduction in lisinopril-treated subjects. Left ventricular diastolic function showed no significant changes in either group. The vascular pathophysiologic alterations of ISH-a decreased aortic distensibility-can be improved with long-term lisinopril treatment, whereas values deteriorate further in placebo-treated subjects. These results, in one of the first studies including subjects with previously untreated ISH only, indicate that lisinopril treatment might favorably influence the cardiovascular risk of ISH.

Home blood pressure measurement: reproducibility and relationship with left ventricular mass

OBJECTIVE

To evaluate the reproducibility and relationship with left ventricular mass index of home blood pressure in comparison with ambulatory and office blood pressures.

METHODS

We measured home, ambulatory and office blood pressures of 84 previously untreated hypertensive patients, aged 60-74 years, from primary care, at baseline and after 12 weeks, without active intervention in between. Left ventricular mass index was determined echocardiographically during week 12.

RESULTS

Decreases in systolic and diastolic blood pressures were found after 12 weeks for mean home and office blood pressures (P<0.05), but not for mean ambulatory blood pressure. The coefficients of reproducibility for systolic and diastolic ambulatory blood pressures were 26.4 and 16.0, respectively. Correlation coefficients for correlation of left ventricular mass index to ambulatory blood pressure (0.51 and 0.36) were higher than the correlation coefficients for home (0.31 and 0. 16) and office (0.32 and 0.21) blood pressures, for systolic and diastolic values, respectively. However, we could find no statistically significant difference among the correlation coefficients for all three types of measurements.

CONCLUSIONS

Home blood pressure was considerably less reproducible than ambulatory blood pressure and no different from office blood pressure in this respect. The relationship with left ventricular mass index appeared to be stronger for ambulatory than it was for home and office blood pressures, although not statistically significant so.

A simple nomogram for determination of echocardiographic left ventricular geometry

Recent data have shown that left ventricular (LV) geometry provides additional information on the simple dichotomy of presence or absence of LV hypertrophy with regard to cardiovascular risk of hypertensive patients. A "new" class of concentric remodeling was created, identifying a rather large group of hypertensive patients who do have increased risk despite no LV hypertrophy. Because determination of LV geometry is not easy, our objective was to develop a nomogram enabling determination of LV geometry in a simple way. The geometric classification is based on the combination of increased relative wall thickness and LV hypertrophy (LV mass index > or = 125 g/m2) both of which are calculated from wall thickness and end-diastolic diameter. In the nomogram the calculated cutoff lines for relative wall thickness and left ventricular hypertrophy are plotted, forming 4 quadrants that represent the geometric classes. Two nomograms are made: 1 based on Penn convention measurement calculations and 1 based on American Society of Echocardiography convention measurements. This nomogram provides a simple way to determine LV geometry, and thus a quick assessment of the additional cardiovascular risk of the hypertensive patient. This is especially important for subjects with concentric remodeling, who would otherwise not be identified as having increased risk for cardiovascular disease.

Effects of amlodipine and lisinopril on left ventricular mass and diastolic function in previously untreated patients with mild to moderate diastolic hypertension

The aim of the study was to compare the effects of two long-acting antihypertensive agents, the calcium-antagonist amlodipine and the ACE inhibitor lisinopril, on left ventricular mass and diastolic filling in patients with mild to moderate diastolic hypertension from primary care centres. It is a 1-year prospective, double-blind, randomized, parallel group, comparative study. Patients between 25 and 75 years of age with untreated hypertension with elevated diastolic blood pressure (> or = 95 mmHg) on three occasions (twice on the first visit and once only on the second and third visits) were recruited from a population survey. After 4 weeks placebo run-in 71 patients were randomized to dosages of amlodipine 5-10 mg or lisinopril 10-20 mg, which were titrated on the basis of the effects on blood pressure. Fifty-nine patients completed the study period. Primary endpoints were left ventricular mass index and early to atrial peak filling velocity. Office and ambulatory blood pressure and other echocardiographic measurements were considered secondary. Decrease in blood pressure was equal for both treatment regimens. A statistically significant decrease in left ventricular mass index in both treatment groups was observed: -11.0 g/m2 (95% CI: -6.0, -16.1) in the amlodipine group and -12.6 g/m2 (95% CI: -8.2, -17.0) in the lisinopril group. The higher the baseline value of left ventricular mass before treatment, the more the decrease after treatment. Early to atrial peak filling velocity did not change significantly within the treatment groups: +0.07 (95% CI: -0.01, +0.15) in the amlodipine group and +0.01 (95% CI: -0.06, +0.08) in the lisinopril group. However, analysis of time measurements of the early peak showed significant changes for both treatment groups. No significant differences in primary and secondary endpoints between treatment groups were found. Twelve patients did not complete the study, seven in amlodipine and five in lisinopril, basically due to adverse events. The effects of amlodipine and lisinopril on left ventricular mass and early to atrial filling peak velocity after 1 year of treatment in patients with previously untreated mild to moderate hypertension are similar. Further studies are recommended, particularly with a larger sample size and a follow-up of longer duration.

Effect of quinapril and triamterene/hydrochlorothiazide on cardiac and vascular end-organ damage in isolated systolic hypertension

We compared, in a prospective double-blind randomized study, the effect of the angiotensin-converting enzyme inhibitor quinapril (QUI) with that of triamterene/hydrochlorothiazide (THCT) treatment on cardiovascular end-organ damage in subjects with untreated isolated systolic hypertension (ISH). End-organ damage measurements, performed initially and after 6 and 26 weeks of treatment, included echocardiographic determination of left ventricular mass index (LVMI) and of diastolic function and measurement of aortic distensibility and peripheral vascular resistance. Blood pressure was significantly reduced in the 44 subjects (21 QUI, 23 THCT) completing the study. Both LVMI and aortic distensibility had changed at 6 weeks, with comparable improvements in both groups. LV diastolic function showed overall no significant changes, although patterns of early filling did differ between the two drug groups. Peripheral vascular resistance appeared to increase between 6 and 26 weeks in THCT subjects only, along with a decreased aortic distensibility. Blood pressure and LV mass were rapidly and markedly reduced in both treatment groups of ISH subjects, paralleled by an improvement of aortic distensibility. In interpreting these results, the pathophysiologic alterations in ISH need to be taken into account, because these differ strongly from those in diastolic hypertension. Results of LV diastolic function and peripheral vascular resistance were less clear but appear to show less favorable changes in the THCT subjects treatment group.

High prevalence of concentric remodeling in elderly individuals with isolated systolic hypertension from a population survey

Echocardiographic determination of left ventricular mass index (LVMI) is shown to be valuable in the assessment of cardiovascular risk. Determination of left ventricular geometry, including concentric remodeling, provides additional prognostic information. In isolated systolic hypertension (ISH), the few echocardiographic studies available show an increased LVMI, but criteria and patient populations differ. No comparison with diastolic hypertension (DH) has been made, nor has left ventricular geometry (with concentric remodeling) been evaluated. We compared both LVMI and left ventricular geometry of newly diagnosed ISH subjects with normotensive and DH subjects, all previously untreated and from the same population. The echocardiographic LVMI of 97 previously untreated ISH subjects (4 x systolic pressure > or = 160 mm Hg, diastolic pressure < 95 mm Hg) was clearly elevated compared with values in age- and sex-matched normotensive subjects (98 and 71 g/m2, respectively; P < .001). The geometric pattern was abnormal in most ISH subjects, with a high prevalence (43%) of concentric remodeling. Both LVMI and left ventricular geometry of ISH subjects did not differ significantly from values in DH subjects (LVMI, 92 g/m2; concentric remodeling, 56%). Sex differences in LV geometry in ISH were present only with the Framingham criteria, not with the Koren criteria. This study shows a high prevalence of concentric remodeling in elderly individuals with previously untreated ISH. The increase of LVMI and abnormality in left ventricular geometry are comparable with those in DH subjects, further defining the place of ISH as a cardiovascular risk factor in the elderly. Whether there are sex differences in cardiac adaptation in ISH and whether the geometric classification can be used to adjust treatment remain to be investigated.

Acceptance and side effects of ambulatory blood pressure monitoring: evaluation of a new technology

Ambulatory blood pressure (BP) monitoring is probably becoming a clinically useful procedure for the evaluation of hypertensive patients. Previous reports have shown that the devices are safe and serious side effects are rare. Discomfort and inconveniences associated with its use are more frequent. In this study, patient acceptance of ambulatory blood pressure monitoring (ABPM) was compared with acceptance of other diagnostic procedures and their side effects were assessed. Patients were asked to fill in a form and 129 of 166 patients responded. The acceptance was measured with a visual analogue scale which ranged from 'very annoying' on the left to 'not annoying at all' on the right. All forms were collected anonymously. Mean distance (cm) of the visual likert scale was 8.6 to 9.4 for the diagnostic procedures frequently used in routine patient care. Ambulatory BP measurement (ABPM) scored 6.1 cm. Reported side effects (in 27% of patients) were: plan (9%), skin irritation (8%), noisy device (8%), inconvenience with work (3%), haematoma (2%) and other (4%). Reports from the patients on sleep quality were: 23% normal, 61% minor disturbance, 14% had sleep, and 2% did not sleep at all. It can be concluded that ambulatory BP monitoring was the diagnostic procedure with the lowest patient acceptance. Side effects of this new technology were reported by 27% of patients. However, risks are relatively minor. Sleep disturbances were very frequent and was a serious problem for 16% of patients.

Predictive value of ambulatory blood pressure shortly after withdrawal of antihypertensive drugs in primary care patients

OBJECTIVE

To determine whether ambulatory blood pressure eight weeks after withdrawal of antihypertensive medication is a more sensitive measure than seated blood pressure to predict blood pressure in the long term.

DESIGN

Patients with previously untreated diastolic hypertension were treated with antihypertensive drugs for one year; these were withdrawn in patients with well controlled blood pressure, who were then followed for one year.

SETTING

Primary care.

SUBJECTS

29 patients fulfilling the criteria for withdrawal of antihypertensive drugs.

MAIN OUTCOME MEASURES

Sensitivity, specificity, and positive and negative predictive value of seated and ambulatory blood pressure eight weeks after withdrawal of antihypertensive drugs.

RESULTS

Eight weeks after withdrawal of medication, mean diastolic blood pressure returned to the pretreatment level on ambulatory measurements but not on seated measurements. One year after withdrawal of medication, mean diastolic blood pressure had returned to the pretreatment level both for seated and ambulatory blood pressure. For ambulatory blood pressure, the sensitivity and the positive predictive value eight weeks after withdrawal of medication were superior to those for seated blood pressure; specificity and negative predictive value were comparable for both types of measurement. Receiver operating characteristic curves showed that the results were not dependent on the cut off values that were used.

CONCLUSION

Ambulatory blood pressure eight weeks after withdrawal of antihypertensive drugs predicts long term blood pressure better than measurements made when the patient is seated.

Prediction of the left ventricular mass from the electrocardiogram in systemic hypertension

Although echocardiography provides a reliable method to determine left ventricular (LV) mass, it may not be available in all settings. Numerous electrocardiographic (ECG) criteria for the detection of LV hypertrophy have been developed, but few attempts have been made to predict the LV mass itself from the ECG. In a community-based survey program in the general population, 277 subjects were identified with untreated diastolic hypertension (diastolic blood pressure 95 to 115 mm Hg, 3 occasions) or isolated systolic hypertension (diastolic blood pressure <95 mm Hg and systolic blood pressure 160 to 220 mm Hg, 3 occasions). All subjects underwent ECG and echocardiography on the same day. A multiple linear regression analysis was performed using a random training sample of the data set (n = 185). The independent variables included both ECG and non-ECG variables. The resulting model was used to predict the LV mass in the remainder of the data set, the validation sample (n = 92). Using sex, age, body surface area, the S-voltage in V1 and V4, and the duration of the terminal P in V1 as independent variables, the model explained 45% of the variance (r = 0.67) in the training sample and 42% (r = 0.65) in the validation sample. This result exceeded that of 2 existing ECG models for LV mass (r = 0.40 and 0.41). The correlations between LV mass and combinations of ECG variables used for the detection of LV hypertrophy, such as the Sokolow-Lyon Voltage (r = 0.03) and the Cornell Voltage (r = 0.31), were comparatively low. In settings where echocardiography is not available or is too expensive and time-consuming, prediction of the LV mass from the ECG may offer a valuable alternative.

Measuring quality of life with the sickness impact profile: a pilot study

A pilot-study was done to investigate the applicability of the sickness impact profile (SIP) in ex-ICU patients. For this study 221 consecutively admitted patients were reviewed retrospectively after excluding children, deceased patients and readmissions. SIP was assessed in these patients by either interview or questionnaire. These were divided into three groups: i) Patients interviewed at home (n = 26). ii) Patients receiving the SIP-questionnaire by mail (n = 93). iii) As for group ii, but after receiving a telephone invitation to participate (n = 102). Highest mean SIP-score was found in group i (16.3). Groups ii and iii scored 10.2 and 7.9 respectively. Analysis of variance demonstrated overall SIP-scores of these groups to be significantly different. The response in group iii (77%) was significantly higher compared to group ii (56%). Data collection in Group i appeared to be most expensive costing $13.20 per patient, followed by group iii ($3.79) and group ii ($2.56). It is concluded that the self-administered SIP is suitable for measuring outcome in ICU-patients and is much cheaper than the direct interview technique. The 3 different approaches should be considered as independent methods of which individual results cannot be compared. The response can be improved significantly by calling the patients before sending the questionnaire.