An appeal to our government for nationwide policies in the prevention of cardiovascular disease.

The high prevalence and burden of cardiovascular diseases (CVD) is largely attributable to unhealthy lifestyle factors such as smoking, alcohol consumption, physical inactivity and unhealthy food habits. Prevention of CVD, through the promotion of healthy lifestyles, appears to be a Sisyphean task for healthcare professionals, as the root causes of an unhealthy lifestyle lie largely outside their scope. Since most lifestyle choices are habitual and a response to environmental cues, rather than rational and deliberate choices, nationwide policies targeting the context in which lifestyle behaviours occur may be highly effective in the prevention of CVD. In this point-of-view article, we emphasise the need for government policies beyond those mentioned in the National Prevention Agreement in the Netherlands to effectively reduce the CVD risk, and we address the commonly raised concerns regarding 'paternalism'.

The challenge of choosing in cardiovascular risk management.

Cardiovascular disease (CVD) is a major cause of morbidity and mortality worldwide. For many years guidelines have listed optimal preventive therapy. More recently, novel therapeutic options have broadened the options for state-of-the-art CV risk management (CVRM). In the majority of patients with CVD, risk lowering can be achieved by utilising standard preventive medication combined with lifestyle modifications. In a minority of patients, add-on therapies should be considered to further reduce the large residual CV risk. However, the choice of which drug combination to prescribe and in which patients has become increasingly complicated, and is dependent on both the absolute CV risk and the reason for the high risk. In this review, we discuss therapeutic decisions in CVRM, focusing on (1) the absolute CV risk of the patient and (2) the pros and cons of novel treatment options.

Lifestyle management to prevent atherosclerotic cardiovascular disease: evidence and challenges.

Lifestyle management is the cornerstone of both primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD) and the importance of lifestyle management is emphasised by all major guidelines. Despite this, actual implementation of lifestyle management is poor. Lifestyle modification includes smoking cessation, weight loss, dietary change, increasing physical inactivity, and stress management. This review summarises evidence-based opportunities and challenges for healthcare professionals to promote healthy lifestyles at an individual level for the prevention of ASCVD.

The scientific basis for secondary prevention of coronary artery disease: recent contributions from the Netherlands.

While the beneficial effects of secondary prevention of cardiovascular disease are undisputed, implementation remains challenging. A gap between guideline-mandated risk factor targets and clinical reality was documented as early as the 1990s. To address this issue, research groups in the Netherlands have performed several major projects. These projects address innovative, multidisciplinary strategies to improve medication adherence and to stimulate healthy lifestyles, both in the setting of cardiac rehabilitation and at dedicated outpatient clinics. The findings of these projects have led to changes in prevention and rehabilitation guidelines.

Health literacy and hypertension outcomes in a multi-ethnic population: the HELIUS study.

BACKGROUND: Hypertension disproportionately affects ethnic minority groups. Although health literacy may play role in these ethnic inequalities, little is known about the extent to which health literacy affects hypertension prevalence, awareness, treatment and control in different ethnic groups. Therefore, we assessed these associations in a multi-ethnic population. METHODS: Baseline data from the HELIUS study were used including participants of Dutch (n = 1948), South-Asian Surinamese (n = 2054) and African Surinamese (n = 1932) origin aged 18-70 years, who lived in Amsterdam, the Netherlands, were fluent in Dutch and underwent health literacy assessment through the Rapid Estimate of Adult Literacy in Medicine-Dutch (REALM-D). The REALM-D was categorized either as low (<60 sumscore) or adequate (≥60 sumscore) health literacy. Participants completed questionnaires and underwent physical examination. RESULTS: After adjusting for confounding variables, Dutch [odds ratio (OR) 2.02; 95% confidence interval (CI), 1.11-3.64] and African Surinamese (OR 1.36; 1.03-1.79) with low health literacy were more likely than those with adequate health literacy to have hypertension, whereas in South-Asian Surinamese this association was not significant. No significant associations were found between health literacy and hypertension awareness, treatment and control in any of the ethnic groups. CONCLUSION: Findings indicate that health literacy is associated with hypertension prevalence in selected ethnic groups, but not with hypertension awareness, treatment and control. Targeting health literacy might be an entry point for tackling ethnic inequalities in hypertension prevalence. To substantially reduce these inequalities, further research is needed to explore other factors and pathways through which health literacy may impact hypertension outcomes in different ethnic groups.

Readmission and mortality in patients ≥70 years with acute myocardial infarction or heart failure in the Netherlands: a retrospective cohort study of incidences and changes in risk factors over time.

OBJECTIVES: To determine the risk of first unplanned all-cause readmission and mortality of patients ≥70 years with acute myocardial infarction (AMI) or heart failure (HF) and to explore which effects of baseline risk factors vary over time. METHODS: A retrospective cohort study was performed on hospital and mortality data (2008) from Statistics Netherlands including 5,175 (AMI) and 9,837 (HF) patients. We calculated cumulative weekly incidences for first unplanned all-cause readmission and mortality during 6 months post-discharge and explored patient characteristics associated with these events. RESULTS: At 6 months, 20.4% and 9.9% (AMI) and 24.6% and 22.4% (HF) of patients had been readmitted or had died, respectively. The highest incidences were found in week 1. An increased risk for 14-day mortality after AMI was observed in patients who lived alone (hazard ratio (HR) 1.57, 95% confidence interval (CI) 1.01-2.44) and within 30 and 42 days in patients with a Charlson Comorbidity Index ≥3. In HF patients, increased risks for readmissions within 7, 30 and 42 days were found for a Charlson Comorbidity Index ≥3 and within 42 days for patients with an admission in the previous 6 months (HR 1.42, 95% CI 1.12-1.80). Non-native Dutch HF patients had an increased risk of 14-day mortality (HR 1.74, 95% CI 1.09-2.78). CONCLUSION: The risk of unplanned readmission and mortality in older AMI and HF patients was highest in the 1st week post-discharge, and the effect of some risk factors changed over time. Transitional care interventions need to be provided as soon as possible to prevent early readmission and mortality.

Ethnic differences in metabolic cardiovascular risk among normal weight individuals: Implications for cardiovascular risk screening. The HELIUS study.

BACKGROUND AND AIMS: Cardiovascular disease (CVD) risk factors may occur among a substantial proportion of normal weight individuals, particularly among some ethnic minorities. It is unknown how many of these individuals would be missed by commonly applied eligibility criteria for cardiovascular risk screening. Thus, we aim to determine cardiovascular risk and eligibility for cardiovascular risk screening among normal weight individuals of different ethnic backgrounds. METHODS AND RESULTS: Using the HELIUS study (Amsterdam, The Netherlands), we determined cardiovascular risk among 6910 normal weight individuals of Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Moroccan and Turkish background. High cardiovascular risk was approximated by high metabolic risk based on blood pressure, HDL, triglycerides and fasting glucose. Eligibility criteria for screening were derived from Dutch CVD prevention guidelines and include age ≥ 50 y, family history of CVD, or current smoking. Ethnic group comparisons were made using logistic regression. Age-adjusted proportions of high metabolic risk ranged from 12.6% to 38.4% (men) and from 2.7% to 11.5% (women). This prevalence was higher among most ethnic minorities than the Dutch, especially among women. For most ethnic groups, 79.9%-86.7% of individuals with high metabolic risk were eligible for cardiovascular risk screening. Exceptions were Ghanaian women (58.8%), Moroccan men (70.9%) and Moroccan women (45.0%), although age-adjusted proportions did not differ between groups. CONCLUSION: Even among normal weight individuals, high cardiovascular metabolic risk is more common among ethnic minorities than among the majority population. Regardless of ethnicity, most normal weight individuals with increased risk are eligible for cardiovascular risk screening.

[Is healthcare consumption in the country of origin among Moroccan and Turkish migrants of older age (55+) associated with less use of care in the Netherlands?] / Gaat zorggebruik in het land van herkomst onder oudere Turkse en Marokkaanse migranten gepaard met minder zorggebruik in Nederland? Een combinatie van HELIUS-data met Achmea registratiedata.

A substantial part of all Dutch people of Turkish and Moroccan origin use healthcare in the country of origin when travelling to their country of origin for a shorter or longer period of time (21% and 10%, respectively). If using care in the country of origin leads to avoidance of care in the Netherlands, this could threaten the continuity of care. We linked data of the HELIUS study to health insurance data. We examined the relationship between healthcare utilisation in the country of origin and the Netherlands, in the period of 2010-2015, adjusting for health status as an indicator of need. Contrary to our expectations, Dutch people of Turkish or Moroccan origin using healthcare consumption in the country of origin utilise more care in the Netherlands than individuals that do not utilize healthcare in the country of origin. Thus, our results do not provide any indication for avoidance of healthcare in the Netherlands among this group of older migrants in the Netherlands.

The cardiac care bridge program: design of a randomized trial of nurse-coordinated transitional care in older hospitalized cardiac patients at high risk of readmission and mortality.

BACKGROUND: After hospitalization for cardiac disease, older patients are at high risk of readmission and death. Although geriatric conditions increase this risk, treatment of older cardiac patients is limited to the management of cardiac diseases. The aim of this study is to investigate if unplanned hospital readmission and mortality can be reduced by the Cardiac Care Bridge transitional care program (CCB program) that integrates case management, disease management and home-based cardiac rehabilitation. METHODS: In a randomized trial on patient level, 500 eligible patients ≥ 70 years and at high risk of readmission and mortality will be enrolled in six hospitals in the Netherlands. Included patients will receive a Comprehensive Geriatric Assessment (CGA) at admission. Randomization with stratified blocks will be used with pre-stratification by study site and cognitive status based on the Mini-Mental State Examination (15-23 vs ≥ 24). Patients enrolled in the intervention group will receive a CGA-based integrated care plan, a face-to-face handover with the community care registered nurse (CCRN) before discharge and four home visits post-discharge. The CCRNs collaborate with physical therapists, who will perform home-based cardiac rehabilitation and with a pharmacist who advices the CCRNs in medication management The control group will receive care as usual. The primary outcome is the incidence of first all-cause unplanned readmission or mortality within 6 months post-randomization. Secondary outcomes at three, six and 12 months after randomization are physical functioning, functional capacity, depression, anxiety, medication adherence, health-related quality of life, healthcare utilization and care giver burden. DISCUSSION: This study will provide new knowledge on the effectiveness of the integration of geriatric and cardiac care. TRIAL REGISTRATION: NTR6316 . Date of registration: April 6, 2017.

Detection of titanium particles in human liver and spleen and possible health implications.

BACKGROUND: Titanium dioxide (TiO2) is produced at high volumes and applied in many consumer and food products. Recent toxicokinetic modelling indicated the potential of TiO2 to accumulate in human liver and spleen upon daily oral exposure, which is not routinely investigated in chronic animal studies. A health risk from nanosized TiO2 particle consumption could not be excluded then. RESULTS: Here we show the first quantification of both total titanium (Ti) and TiO2 particles in 15 post-mortem human livers and spleens. These low-level analyses were enabled by the use of fully validated (single particle) inductively coupled plasma high resolution mass spectrometry ((sp)ICP-HRMS) detection methods for total Ti and TiO2 particles. The presence of TiO2 in the particles in tissues was confirmed by Scanning Electron Microscopy with energy dispersive X-ray spectrometry. CONCLUSIONS: These results prove that TiO2 particles are present in human liver and spleen, with ≥24% of nanosize (< 100 nm). The levels are below the doses regarded as safe in animals, but half are above the dose that is deemed safe for liver damage in humans when taking into account several commonly applied uncertainty factors. With these new and unique human data, we remain with the conclusion that health risks due to oral exposure to TiO2 cannot be excluded.

Ethnic disparities in estimated cardiovascular disease risk in Amsterdam, the Netherlands : The HELIUS study.

BACKGROUND: Ethnic differences have been reported in cardiovascular disease (CVD) risk factors. It is still unclear which ethnic groups are most at risk for CVD when all traditional CVD risk factors are considered together as overall risk. OBJECTIVES: To examine ethnic differences in overall estimated CVD risk and the risk factors that contribute to these differences. DESIGN: Using data of the multi-ethnic HELIUS study (HEalthy LIfe in an Urban Setting) from Amsterdam, we examined whether estimated CVD risk and risk factors among those eligible for CVD risk estimation differed between participants of Dutch, South Asian Surinamese, African Surinamese, Ghanaian, Turkish and Moroccan origin. Using the Systematic COronary Risk Evaluation (SCORE) algorithm, we estimated risk of fatal CVD and risk of fatal plus non-fatal CVD. These risks were compared between ethnic groups via age-adjusted linear regression analyses. RESULTS: The SCORE algorithm was applicable to 9,128 participants. Relative to the fatal CVD risk of participants of Dutch origin, South Asian Surinamese participants showed a higher fatal CVD risk, Ghanaian males a lower fatal CVD risk, and participants of other ethnic origins a similar fatal CVD risk. For fatal plus non-fatal CVD risk, African Surinamese and Turkish men also showed a higher risk. When diabetes was incorporated in the CVD risk algorithm, all but Ghanaian men showed a higher CVD risk relative to the participants of Dutch origin (betas ranging from 0.98-3.10%). The CVD risk factors that contribute the most to these ethnic differences varied between ethnic groups. CONCLUSION: Ethnic minority groups are at a greater estimated risk of fatal plus non-fatal CVD relative to the group of native Dutch. Further research is necessary to determine whether this will translate to ethnic differences in CVD incidence and, if so, whether ethnic-specific CVD prevention strategies are warranted.

Smoking cessation in European patients with coronary heart disease. Results from the EUROASPIRE IV survey: A registry from the European Society of Cardiology.

OBJECTIVE: We investigated smoking cessation rates in coronary heart disease (CHD) patients throughout Europe; current and as compared to earlier EUROASPIRE surveys, and we studied characteristics of successful quitters. METHODS: Analyses were done on 7998 patients from the EUROASPIRE-IV survey admitted for myocardial infarction, unstable angina and coronary revascularisation. Self-reported smoking status was validated by measuring carbon monoxide in exhaled air. RESULTS: Thirty-one percent of the patients reported being a smoker in the month preceding hospital admission for the recruiting event, varying from 15% in centres from Finland to 57% from centres in Cyprus. Smoking rates at the interview were also highly variable, ranging from 7% to 28%. The proportion of successful quitters was relatively low in centres with a low number of pre- event smokers. Overall, successful smoking cessation was associated with increasing age (OR 1.50; 95% CI 1.09-2.06) and higher levels of education (OR 1.38; 95% CI 1.08-1.75). Successful quitters more frequently reported that they had been advised (56% vs. 47%, p < .001) and to attend (81% vs. 75%, p < .01) a cardiac rehabilitation programme. CONCLUSION: Our study shows wide variation in cessation rates in a large contemporary European survey of CHD patients. Therefore, smoking cessation rates in patients with a CHD event should be interpreted in the light of pre-event smoking prevalence, and caution is needed when comparing cessation rates across Europe. Furthermore, we found that successful quitters reported more actions to make healthy lifestyle changes, including participating in a cardiac rehabilitation programme, as compared with persistent smokers.

Ethnic differences in metabolite signatures and type 2 diabetes: a nested case-control analysis among people of South Asian, African and European origin.

Accumulation of metabolites may mark or contribute to the development of type 2 diabetes mellitus (T2D), but there is a lack of data from ethnic groups at high risk. We examined sphingolipids, acylcarnitines and amino acids, and their association with T2D in a nested case-control study among 54 South Asian Surinamese, 54 African Surinamese and 44 Dutch in the Netherlands. Plasma metabolites were determined at baseline (2001-2003), and cumulative prevalence and incidence of T2D at follow-up (2011-2012). Weighted linear and logistic regression analyses were used to study associations. The mean level of most sphingolipids was lower, and amino-acid levels higher, in the Surinamese groups than among the Dutch. Surinamese individuals had higher mono- and polyunsaturated acylcarnitines and lower plasma levels of saturated acylcarnitine species than the Dutch. Several sphingolipids and amino acids were associated with T2D. Although only the shorter acylcarnitines seemed associated with prevalent T2D, we found an association of all acylcarnitines (except C0, C18 and C18:2) with incident T2D. Further analyses suggested a potentially different association of several metabolites across ethnic groups. Extension and confirmation of these findings may improve the understanding of ethnic differences and contribute to early detection of increased individual risk.

[Societal aspects of the risk of cardiovascular disease]. / Maatschappelijke aspecten van het risico op hart- en vaatziekten.

A 57-year-old man of Turkish descent is treated for coronary artery disease. In addition to drug treatment and percutaneous revascularization, modification of lifestyle-related risk factors is indicated. His risk profile includes smoking, hypertension and inadequate physical activity. Adherence to medication is suboptimal and his wife is a smoker too. Limited health literacy and acculturation, and resource limitations impede adequate lifestyle changes. Guidance of this patient is challenging; it is not straightforward to influence the societal components of his issues from a medical office. Evidence-based lifestyle interventions are scarce, and their validation - if validated at all - was performed in populations that are not representative of the patient in question. However, physicians can contribute to achieving societal change by participating in national programs aimed at improving infrastructure, improving health literacy, development of ethnicity-specific interventions, availability of healthy food, discouragement of smoking, and creating an infrastructure that promotes physical activity in daily life.