Dietary management of patients at high risk for cardiovascular disease; EUROASPIRE V.

BACKGROUND: Dietary prevention of cardiovascular risk factors is seldom implemented. AIM: We assessed the dietary changes made by subjects at high risk of cardiovascular disease (CVD). DESIGN AND SETTING: Cross-sectional, multicentre observational study (European Society of Cardiology - ESC EORP-EUROASPIRE V Primary Care) including 78 centres from 16 ESC countries. METHODS: Participants aged 18-79 years, devoid of CVD but treated with antihypertensive and/or lipid-lowering and/or antidiabetic therapy were interviewed >6 months and <2 years after medication initiation. Information regarding dietary management was collected by questionnaire. RESULTS: 2759 participants (overall participation rate 70.2%, 1589 women, 1415 aged ≥60 years, 43.5% with obesity, 71.1% on antihypertensive, 29.2% on lipid-lowering and 31.5% on antidiabetic treatment). Among participants with obesity, 47.7% reported having received dietary advice to lose weight [range: 24.7% (Greece) to 71.8% (Lithuania)]. Among participants on antihypertensive drug therapy, 53.9% reported being on a blood pressure lowering diet [range: 5.6% (UK) to 90.4% (Greece)]; a reduction of salt intake in the last three years was reported by 71.4% [range: 12.5% (Sweden) to 89.7% (Egypt)]. Among participants on lipid-lowering therapy, 56.0% reported being on a lipid lowering diet [range: 7.1% (Sweden) to 90.3% (Egypt)]. Among participants with diabetes, 57.2% reported being on a diet [range: 21.6% (Romania) to 95.1% (Bosnia & Herzegovina)]; a reduction in sugar intake was reported by 80.8% [range: 56.5% (Sweden) to 96.7% (Russian Federation)]. CONCLUSIONS: In ESC countries, fewer than 60% of participants at high CVD risk report being on a specific diet, with wide differences between countries.

Treatment goal attainment for secondary prevention in coronary patients with or without diabetes mellitus - Polish multicenter study POLASPIRE.

Introduction: Cardiovascular disease is still a leading cause of death in Poland and across Europe. The aim of this study was to assess the attainment of the main treatment goals for secondary cardiovascular prevention in coronary patients with or without diabetes mellitus (DM) in Poland. Material and methods: The study group included 1026 patients (65.5 ±9 y.o.; males: 72%) included at least 6 months after the index hospitalisation for myocardial infarction, unstable angina, elective percutaneous coronary intervention or coronary artery bypass surgery. The target and treatment goals were defined according to the 2016 European Society of Cardiology guidelines on cardiovascular prevention. Results: Patients with DM (n = 332; 32%) were slightly older compared to non-diabetic (n = 694) individuals (67.2 ±7 vs. 64.6 ±9 years old; p < 0.0001). The DM goal was achieved in 196 patients (60%). The rate of primary (LDL: 51% vs. 35%; p < 0.0001) and secondary (non-HDL: 56% vs. 48%; p < 0.02) goal attainment was higher in DM(+) compared to DM(-) patients. The rate of target blood pressure was lower in DM(+) than in normoglycemic patients (52% vs. 61% at < 140/90 mm Hg, p < 0.01. As expected, goal achievement of normal weight (9.5% vs. 19%; p < 0.0001) and waist circumference (7% vs. 15%; p < 0.001) was lower in diabetic patients and the rate of regular physical activity was similar (DM+ 12% vs. DM- 14%; p = ns). Finally, there was no difference in active smokers (DM+ 23% vs. DM- 22%; p = ns). Conclusions: Great majority of Polish patients in secondary prevention do not achieve treatment goals. Although lipid goals attainment is better in DM and the rate of smokers is similar, the management of all risk factors needs to be improved.

Gender differences in risk factor management and pharmacological treatment among CHD patients: Belgian results of the EUROASPIRE IV and EUROASPIRE V surveys.

AIMS: The aim of this study was to provide an up-to-date overview of gender differences or similarities in risk factor control and medical management in the Belgian CHD population. METHODS: All analyses are based on the ESC EORP EUROASPIRE IV and EUROASPIRE V (European Survey Of Cardiovascular Disease Prevention And Diabetes) surveys. Patients between 18 and 80 years old, hospitalised for a first or recurrent coronary event, were included in the survey. RESULTS: Data were available for 10,519 patients, of which 23.9% were women. Women had a worse risk factor profile compared to men. Women were more physical inactive (OR = 1.31, 95% CI = 1.19-1.44), had a higher prevalence of obesity (OR = 1.37, 95% CI = 1.25-1.50) and had a worse LDL-C control (OR = 1.52, 95% CI = 1.36-1.70). Moreover, women were less likely to use ACE-I/ARBs (OR = 0.84, 95% CI = 0.76-0.94) and statins (OR = 0.79, 95% CI = 0.70-0.90). In addition, little gender differences were found in patients' risk factor awareness, except on cholesterol awareness. Women were more aware about their total cholesterol levels (OR = 1.37, 95% CI = 1.21-1.56). CONCLUSION: Despite little to no gender differences in the management of CHD patients, women still have a worse risk factor profile, both in Belgian and in other European high-income countries.

Gender differences in health-related quality of life and psychological distress among coronary patients: Does comorbidity matter? Results from the ESC EORP EUROASPIRE V registry.

AIMS: This study aimed to provide an overview on contemporary gender differences in HRQoL/psychological distress and their relationship with comorbidity burden among European coronary heart disease (CHD) patients. METHODS: Analyses were based on the cross-sectional ESC EORP EUROASPIRE V survey. Consecutive patients (aged 18-80 years), hospitalized for a first or recurrent coronary event were included in this study. Data at hospital discharge and at follow-up (6 to 24 months after hospitalisation) were collected. RESULTS: Data were available for 8261 patients of which 25.8% women. Overall, women reported a worse EQ-5D-5L index score (0.73 vs. 0.81; P < 0.001), EQ-VAS (63.1 vs. 66.0; P = 0.001), global HeartQoL (1.94 vs. 2.26; P < 0.001), physical HeartQoL (1.96 vs. 2.30; P < 0.001), emotional HeartQoL (1.88 vs. 2.18; P < 0.001), HADS-A (6.69 vs. 4.99; P < 0.001), and HADS-D (5.73 vs. 4.62; P < 0.001) compared to men. Also, women were more likely to have comorbidities compared to men (1 comorbidity: 38.7% vs. 35.0%, 2 comorbidities: 9.7% vs. 7.5%; P < 0.001). There is indication that heart failure (EQ-VAS) and diabetes (global HeartQoL, emotional HeartQoL, physical HeartQoL, and HADS-D) interacted with gender and modulate the relationship with HRQoL, in disfavour of women. CONCLUSION: Substantial gender-based health inequalities in terms of HRQoL and psychological distress were found, in disfavour of women. Women had worse HRQoL and psychological distress outcomes when having comorbidities. To a limited extent, comorbidity and women had a negative/synergistic effect on HRQoL. Special attention should be given to this population groups within daily clinical practice.

Assessing the probability of risk factor control in patients with coronary heart disease: results from the ESC-EORP EUROASPIRE V survey.

AIMS: In patients with coronary heart disease (CHD), we investigated whether it is possible to accurately assess the probability of short-term control of risk factors (blood pressure, cholesterol, smoking) based on individual and large-area residential characteristics. METHODS AND RESULTS: We merged individual data of participants from EUROASPIRE V who were hospitalized for CHD (2014-2017) and interviewed and examined for risk factor control (2016-2017), with large-area residential data provided by Eurostat for Nomenclature of Territorial Units for Statistics (NUTS) regions using postal codes. Data from 2562 CHD patients in 16 countries were linked to data from 60 NUTS 2 and 121 NUTS 3 regions. The median time between hospitalization and interview was 14 months. We developed prediction models to assess the probability of risk factor control at interview using data from the time of hospitalization: (i) baseline models including 35 variables on patients' demographic, clinical, and socio-economic characteristics and (ii) extended models additionally considering nine variables on large-area residential characteristics. We calculated and internally validated c-indices to assess the discriminative ability of prediction models. Baseline models showed good discrimination with c-indices of 0.69, 0.70, and 0.76 for blood pressure control, cholesterol control, and smoking cessation, respectively. Extended models for blood pressure, cholesterol, and smoking yielded improved c-indices of 0.72, 0.71, and 0.78, respectively. CONCLUSION: Our results indicate that the probability of risk factor control in CHD patients can be accurately assessed using individual and large-area residential characteristics, allowing for an identification of patients who are less likely to achieve risk factor targets.

Measures of Insulin Resistance as a Screening Tool for Dysglycemia in Patients With Coronary Artery Disease: A Report From the EUROASPIRE V Population.

OBJECTIVE: The optimal screening strategy for dysglycemia (including type 2 diabetes and impaired glucose tolerance) in patients with coronary artery disease (CAD) is debated. We tested the hypothesis that measures of insulin resistance by HOMA indexes may constitute good screening methods. RESEARCH DESIGN AND METHODS: Insulin, C-peptide, glycated hemoglobin A1c, and an oral glucose tolerance test (OGTT) were centrally assessed in 3,534 patients with CAD without known dysglycemia from the fifth European Survey of Cardiovascular Disease Prevention and Diabetes (EUROASPIRE V). Three different HOMA indexes were calculated: HOMA of insulin resistance (HOMA-IR), HOMA2 based on insulin (HOMA2-ins), and HOMA2 based on C-peptide (HOMA2-Cpep). Dysglycemia was diagnosed based on the 2-h postload glucose value obtained from the OGTT. Information on study participants was obtained by standardized interviews. The optimal thresholds of the three HOMA indexes for dysglycemia diagnosis were obtained by the maximum value of Youden's J statistic on receiver operator characteristic curves. Their correlation with clinical parameters was assessed by Spearman coefficients. RESULTS: Of 3,534 patients with CAD (mean age 63 years; 25% women), 41% had dysglycemia. Mean insulin, C-peptide, and HOMA indexes were significantly higher in patients with versus without newly detected dysglycemia (all P < 0.0001). Sensitivity and specificity of the three HOMA indexes for the diagnosis of dysglycemia were low, but their correlation with BMI and waist circumference was strong. CONCLUSIONS: Screening for dysglycemia in patients with CAD by HOMA-IR, HOMA2-ins, and HOMA2-Cpep had insufficient diagnostic performance to detect dysglycemia with reference to the yield of an OGTT, which should still be prioritized despite its practical drawbacks.

Gender differences in cardiovascular risk factor awareness: Results from the ESC EORP EUROASPIRE V Registry.

BACKGROUND: Patients' risk factor awareness is essential to decrease the risk of recurrent coronary events. The aim of this study was to provide up-to-date evidence on existing gender differences in the patients' knowledge of risk factors and information provided by healthcare professionals. METHODS: Analyses were based on the cross-sectional ESC EORP EUROASPIRE V survey, including data on CHD patients across 27 European countries. Consecutive patients (18-80 years), hospitalized for a coronary event or surgical procedure, were retrospectively identified. Information on risk factor awareness was collected from medical records, medical examination, and structured questionnaires during the study visit (six months to two years after hospitalization). RESULTS: Patient information was available for 8261 patients, of which 25.8% were women. Although women with obesity were significantly less aware about their actual (OR = 0.66, CI = 0.52-0.85) and target weight levels (OR = 0.66, CI = 0.54-0.81), no significant gender differences in risk factor awareness were found in disfavour of women. Remarkably, women with hypertension and women with raised low-density lipoprotein cholesterol (LDL-C) levels were even more aware about their target blood pressure levels (OR = 1.21, CI = 1.01-1.46) and actual cholesterol levels (OR = 1.18, CI = 1.02-1.36), respectively. Moreover, there is some indication that women were more informed by a healthcare professional if they had raised CHD risk factor levels. CONCLUSIONS: Our study showed only few gender differences in disfavour of women in terms of risk factor awareness and information provided by a healthcare professional. Nevertheless, previous EUROASPIRE V findings demonstrated that women still have a poorer risk factor control in secondary CHD prevention.

Gender differences in lifestyle management among coronary patients and the association with education and age: results from the ESC EORP EUROASPIRE V registry.

BACKGROUND: Lifestyle management is essential in the secondary care of coronary heart disease (CHD) patients. Little evidence is available about gender differences in lifestyle counselling and lifestyle compliance. This study aimed to provide an overview on potential gender differences in lifestyle advice provided by a healthcare professional and patients' lifestyle compliance. METHODS AND RESULTS: Analyses were based on the cross-sectional ESC EORP EUROASPIRE V survey including data on CHD patients across 27 European countries. Consecutive patients <80 years, hospitalized for a first or recurrent coronary event, were included in the study. Information on lifestyle management was collected from medical records, medical examination, and structured questionnaires during patient interviews (≥6 months to <2 years after hospitalization). Data were available for 8261 patients of whom 25.8% women. Overall, no gender differences were observed in lifestyle advice provided by a healthcare professional for smoking cessation advice, dietary advice, advice on losing weight, and physical activity advice (P > 0.05). However, a closer look at the particular actions to adopt a healthy diet revealed that women reported more frequently a reduction of their salt (68.6% vs. 73.7%; P = 0.002), fat (70.8% vs. 74.7%; P = 0.003), and calorie intake (56.8% vs. 60.5%; P = 0.004) compared to men. In contrast, women were less likely to increase their physical activity levels (55.5% vs. 48.0%; P < 0.001). CONCLUSION: Despite little gender differences in lifestyle advice provided by a healthcare professional, lifestyle compliance for physical activity is worse in CHD women. Further actions are needed to increase physical activity levels in female CHD patients.

Saving time by replacing the standardised two-hour oral glucose tolerance test with a one-hour test: Validation of a new screening algorithm in patients with coronary artery disease from the ESC-EORP EUROASPIRE V registry.

AIMS: An oral glucose tolerance test (OGTT) combining fasting (FPG) and 2-hour plasma glucose (2hPG) is the most sensitive method for detecting type 2 diabetes (T2DM). Since it is considered time-consuming, we aim at validating a previously proposed screening algorithm based on a 1-hour plasma glucose (1hPG) with a 12 mmol/L threshold. METHODS: Nine-hundred-eighteen patients with coronary artery disease (CAD) without known T2DM from the EUROASPIRE V cross-sectional survey underwent an OGTT. The reference for T2DM was 2hPG ≥ 11.1 mmol/L. T2DM diagnosis by HbA1c ≥ 6.5%(48 mmol/mol), FPG ≥ 7.0 mmol/L, and 1hPG ≥ 12 mmol/L were compared with the outcome of 2hPG. RESULTS: Mean FPG, HbA1c and 2hPG were 6.1 mmol/L, 5.6%(38 mmol/mol) and 7.8 mmol/L respectively. Ninety-six patients (10%) were diagnosed with T2DM according to 2hPG. Using this definition, in the group with FPG < 6.5 mmol/L and 1hPG < 12 only 5 (1%) were misdiagnosed as false negatives. All patients with a FPG > 8.0 mmol/L and 1hPG > 15.0 mmol/L were identified as having T2DM. According to the algorithm, in 79% of patients T2DM could be excluded by combining FPG < 6.5 mmol/L and 1hPG < 12 mmol/L. CONCLUSIONS: T2DM Screening by means of an algorithm combining FPG and 1hPG limits the demand of a 2hOGTT in 79% of CAD patients without known T2DM. HbA1c did not add to the information derived from this algorithm.

Prediction of recurrent event in patients with coronary heart disease: the EUROASPIRE Risk Model.

AIMS: Most patients with established atherosclerotic cardiovascular disease (CVD) are at very high risk for developing recurrent events. Since this risk varies a lot between patients there is a need to identify those in whom an even more intensive secondary prevention strategy should be envisaged. Using data from the EUROASPIRE IV and V cohorts of coronary heart disease (CHD) patients from 27 European countries, we aimed at developing and internally and externally validating a risk model predicting recurrent CVD events in patients aged < 75 years. METHODS AND RESULTS: Prospective data were available for 12 484 patients after a median follow-up time of 1.7 years. The primary endpoint, a composite of fatal CVD or new hospitalizations for non-fatal myocardial infarction (MI), stroke, heart failure, coronary artery bypass graft, or percutaneous coronary intervention (PCI), occurred in 1424 patients. The model was developed based on data from 8000 randomly selected patients in whom the association between potential risk factors and the incidence of the primary endpoint was investigated. This model was then validated in the remaining 4484 patients. The final multivariate model revealed a higher risk for the primary endpoint with increasing age, a previous hospitalization for stroke, heart failure or PCI, a previous diagnosis of peripheral artery disease, self-reported diabetes and its glycaemic control, higher non-high-density lipoprotein cholesterol, reduced renal function, symptoms of depression and anxiety and living in a higher risk country. The model demonstrated excellent internal validity and proved very adequate in the validation cohort. Regarding external validity, the model demonstrated good discriminative ability in 20 148 MI patients participating in the SWEDEHEART register. Finally, we developed a risk calculator to estimate risks at 1 and 2 years for patients with stable CHD. CONCLUSION: In patients with CHD, fatal and non-fatal rates of recurrent CVD events are high. However, there are still opportunities to optimize their management in order to prevent further disease or death. The EUROASPIRE Risk Calculator may be of help to reach this goal.

Potential for optimizing management of obesity in the secondary prevention of coronary heart disease.

AIMS: Prevention guidelines have identified the management of obese patients as an important priority to reduce the burden of incident and recurrent cardiovascular disease. Still, studies have demonstrated that over 80% of patients with coronary heart disease (CHD) fail to achieve their weight target. Here, we describe advice received and actions reported by overweight CHD patients since being discharged from hospital and how weight changes relate to their risk profile. METHODS AND RESULTS: Based on data from 10 507 CHD patients participating in the EUROASPIRE IV and V studies, we analysed weight changes from hospital admission to the time of a study visit ≥6 and <24 months later. At hospitalization, 34.9% were obese and another 46.0% were overweight. Obesity was more frequent in women and associated with more comorbidities. By the time of the study visit, 19.5% of obese patients had lost ≥5% of weight. However, in 16.4% weight had increased ≥5%. Weight gain in those overweight was associated with physical inactivity, non-adherence to dietary recommendations, smoking cessation, raised blood pressure, dyslipidaemia, dysglycaemia, and lower levels of quality of life. Less than half of obese patients was considering weight loss in the coming month. CONCLUSIONS: The management of obesity remains a challenge in the secondary prevention of CHD despite a beneficial effect of weight loss on risk factor prevalences and quality of life. Cardiac rehabilitation programmes should include weight loss interventions as a specific component and the incremental value of telehealth intervention as well as recently described pharmacological interventions need full consideration.

Poor adherence to lifestyle recommendations in patients with coronary heart disease: results from the EUROASPIRE surveys.

AIMS: Despite the high use of cardioprotective medications, the risk factor control in patients with coronary heart disease (CHD) is still inadequate. Guidelines identify healthy lifestyles as equally important in secondary prevention as pharmacotherapy. Here, we describe reasons for poor lifestyle adherence from the patient's perspective. METHODS AND RESULTS: In the EUROASPIRE IV and V surveys, 16 259 CHD patients were examined and interviewed during a study visit ≥6 months after hospital discharge. Data gathering was fully standardized. The Brief Illness Perception questionnaire was completed by a subsample of 2379 patients. Half of those who were smoking prior to hospital admission, were still smoking; 37% of current smokers had not attempted to quit and 51% was not considering to do so. The prevalence of obesity was 38%. Half of obese patients tried to lose weight in the past month and 61% considered weight loss in the following month. In relation to physical activity, 40% was on target with half of patients trying to do more everyday activities. Less than half had the intention to engage in planned exercise. Only 29% of all patients was at goal for all three lifestyle factors. The number of adverse lifestyles was strongly related to the way patients perceive their illness as threatening. Lifestyle modifications were more successful in those having participated in a cardiac rehabilitation and prevention programme. Patients indicated lack of self-confidence as the main barrier to change their unhealthy behaviour. CONCLUSION: Modern secondary prevention programmes should target behavioural change in all patients with adverse lifestyles.

Functional versus morphological assessment of vascular age in patients with coronary heart disease.

Communicating cardiovascular risk based on individual vascular age (VA) is a well acknowledged concept in patient education and disease prevention. VA may be derived functionally, e.g. by measurement of pulse wave velocity (PWV), or morphologically, e.g. by assessment of carotid intima-media thickness (cIMT). The purpose of this study was to investigate whether both approaches produce similar results. Within the context of the German subset of the EUROASPIRE IV survey, 501 patients with coronary heart disease underwent (a) oscillometric PWV measurement at the aortic, carotid-femoral and brachial-ankle site (PWVao, PWVcf, PWVba) and derivation of the aortic augmentation index (AIao); (b) bilateral cIMT assessment by high-resolution ultrasound at three sites (common, bulb, internal). Respective VA was calculated using published equations. According to VA derived from PWV, most patients exhibited values below chronological age indicating a counterintuitive healthier-than-anticipated vascular status: for VAPWVao in 68% of patients; for VAAIao in 52% of patients. By contrast, VA derived from cIMT delivered opposite results: e.g. according to VAtotal-cIMT accelerated vascular aging in 75% of patients. To strengthen the concept of VA, further efforts are needed to better standardise the current approaches to estimate VA and, thereby, to improve comparability and clinical utility.

INTERASPIRE: an International Survey of Coronary Patients; Their Cardiometabolic, Renal and Biomarker Status; and the Quality of Preventive Care Delivered in All WHO Regions : In Partnership with the World Heart Federation, European Society of Cardiology, Asia Pacific Society of Cardiology, InterAmerican Society of Cardiology, and PanAfrican Society of Cardiology.

PURPOSE OF REVIEW: To describe the INTERASPIRE scientific protocol-an international survey of secondary prevention of coronary heart disease (CHD). RECENT FINDINGS: This international survey is being conducted through National Societies of Cardiology in selected countries from each of the six WHO regions and has the following overall aims: (i) describe prevalence of cardiometabolic and renal risk factors together with biomarkers in CHD patients; (ii) describe current risk factor management through lifestyle changes and cardioprotective drug therapies; (iii) provide an objective assessment of clinical implementation of preventive care by comparison with the lifestyle and risk factor targets defined in international and national guidelines; (iv) investigate the reasons for variation in preventive cardiology practice between regions and countries; and (v) promote the principles of best preventive cardiology practice. This international survey will provide a unique picture of CHD patients; their cardiometabolic, renal and biomarker status; lifestyle and therapeutic management; and the quality of preventive care provided in all WHO regions.

Dyslipidemia Management in Patients with Coronary Artery Disease. Data from the POLASPIRE Survey.

Lipid-lowering in patients with coronary artery disease (CAD) is related to a lower risk of cardiovascular events. We evaluated factors related to the management of hypercholesterolemia in patients with established CAD. Patients were interviewed 6-18 months after hospitalization for an acute coronary syndrome (ACS) or a myocardial revascularization procedure. Statins were prescribed at discharge to 94.4% of patients, while 68.1% of the patients hospitalized for an ACS were prescribed a high-dose statin. Hospitalization in a teaching hospital, percutaneous coronary intervention, cholesterol measurement during hospitalization and the male sex were related to prescription of statins at discharge. The intensity of lipid-lowering therapy in the post-discharge period increased in 17.3%, decreased in 11.7%, and did not change in 71.0% of the patients. The prescription of a lipid-lowering drug (LLD) at discharge (odds ratio 5.88 [95% confidence intervals 3.05-11.34]) and a consultation with a cardiologist (2.48 [1.51-4.08]) were related to the use of LLDs, while age (1.32 [1.10-1.59] per 10 years), loneliness (0.42 [0.19-0.94]), professional activity (1.56 [1.13-2.16]), and diabetes (1.66 [1.27-2.16]) were related to achieving an LDL cholesterol goal 6-18 months after discharge. In conclusion, health-system-related factors are associated with the LLD utilization, whereas mainly patient-related factors are related to the control of hypercholesterolemia following hospitalization for CAD.

Cardiac Rehabilitation: Under-Utilized Globally.

PURPOSE OF REVIEW: Cardiac rehabilitation (CR) is grossly under-utilized. This review summarizes current knowledge about degree of CR utilization, reasons for under-utilization, and strategies to increase use. RECENT FINDINGS: ICCPR's global CR audit quantified for the first time the number of additional CR spots needed per year to treat indicated patients, so there are programs they may use. The first randomized trial of automatic/systematic CR referral has shown it results in significantly greater patient completion. Moreover, the recent update of the Cochrane review on interventions to increase use has provided unequivocal evidence on the significant impact of clinician CR encouragement at the bedside; a course is now available to train clinicians. The USA is leading the way in implementing automatic referral with inpatient-clinician CR discussions. Suggestions to triage patients based on risk to less resource-intensive, unsupervised program models could simultaneously expand capacity and support patient adherence.

Interhospital and interindividual variability in secondary prevention: a comparison of outpatients with a history of chronic coronary syndrome versus outpatients with a history of acute coronary syndrome (the iASPIRE Study).

BACKGROUND: Studying variability in the care provided to secondary prevention coronary heart disease (CHD) outpatients can identify interventions to improve their outcomes. METHODS: We studied outpatients who had an index CHD event in the preceding 6-24 months. Eligible CHD events included acute coronary syndrome (ACS) and coronary revascularisation for stable chronic coronary syndrome (CCS). Site training was provided by a core team and data were collected using standardised methods. RESULTS: Between 2017 and 2019, we enrolled 721 outpatients at nine Irish study sites; 81% were men and mean age was 63.9 (SD ±8.9) years. The study examination occurred a median of 1.16 years after the index CHD event, which was ACS in 399 participants (55%) and stable-CCS in 322. On examination, 42.5% had blood pressure (BP) >140/90 mm Hg, 63.7% had low-density lipoprotein cholesterol (LDL-C) >1.8 mmol/L and 44.1% of known diabetics had an HbA1c >7%. There was marked variability in risk factor control, both by study site and, in particular, by index presentation type. For example, 82% of outpatients with prior-ACS had attended cardiac rehabilitation versus 59% outpatients with prior-CCS (p<0.001) and there were also large differences in control of traditional risk factors like LDL-C (p=0.002) and systolic BP (p<0.001) among outpatients with prior-ACS versus prior-CCS as the index presentation. CONCLUSIONS: Despite international secondary prevention guidelines broadly recommending the same risk factor targets for all adults with CHD, we found marked differences in outpatient risk factor control and management on the basis of hospital location and index CHD presentation type (acute vs chronic). These findings highlight the need to reduce hospital-level and patient-level variability in preventive care to improve outcomes; a lesson that should inform CHD prevention programmes in Ireland and around the world.

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

BACKGROUND: European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) V in primary care was carried out by the European Society of Cardiology EURObservational Research Programme in 2016-2018. The main objective was to determine whether the 2016 Joint European Societies' guidelines on cardiovascular disease prevention in people at high cardiovascular risk have been implemented in clinical practice. METHODS: The method used was a cross-stional survey in 78 centres from 16 European countries. Patients without a history of atherosclerotic cardiovascular disease either started on blood pressure and/or lipid and/or glucose lowering treatments were identified and interviewed ≥ 6 months after the start of medication. RESULTS: A total of 3562 medical records were reviewed and 2759 patients (57.6% women; mean age 59.0 ± 11.6 years) interviewed (interview rate 70.0%). The risk factor control was poor with 18.1% of patients being smokers, 43.5% obese (body mass index ≥30 kg/m2) and 63.8% centrally obese (waist circumference ≥88 cm for women, ≥102 cm for men). Of patients on blood pressure lowering medication 47.0% reached the target of <140/90 mm Hg (<140/85 mm Hg in people with diabetes). Among treated dyslipidaemic patients only 46.9% attained low density lipoprotein-cholesterol target of <2.6 mmol/l. Among people treated for type 2 diabetes mellitus, 65.2% achieved the HbA1c target of <7.0%. CONCLUSION: The primary care arm of the EUROASPIRE V survey revealed that large proportions of people at high cardiovascular disease risk have unhealthy lifestyles and inadequate control of blood pressure, lipids and diabetes. Thus, the potential to reduce the risk of future cardiovascular disease throughout Europe by improved preventive cardiology programmes is substantial.

Smoking cessation in patients with established coronary artery disease: data from the POLASPIRE survey.

BACKGROUND: Smoking cessation in patients with coronary artery disease (CAD) is related to decreased risk of cardiovascular events. AIMS: To evaluate factors related to persistent smoking in patients with established coronary artery disease. METHODS: Patients aged 80 years or younger and hospitalized for acute coronary syndrome or a myocardial revascularization procedure were interviewed 6 to 18 months after the recruiting event. Medical history, smoking behavior, and exposure to environmental smoke were assessed during the interview. Self--reported smoking status was validated by carbon monoxide in exhaled air measurement. Persistent smoking was defined as smoking at the time of interview among those who smoked during the month prior to the recruiting event. RESULTS: We analyzed the data of 1034 patients, including 764 (73.9%) who reported smoking at any time in the past and 296 (28.6%) who smoked within 1 month before the recruiting hospitalization. At the time of the interview, the overall smoking rate was 17.2%, whereas 54.7% of patients were persistent smokers. Secondhand smoke exposure and duration of smoking were associated with lower likelihood whereas older age, high socioeconomic status, cardiac rehabilitation following a cardiovascular event, and consultation with a cardiologist were associated with higher likelihood of smoking cessation. CONCLUSIONS: Over half of all smokers hospitalized for CAD are still smoking 6 to 18 months after discharge. Older age, secondhand smoking, low socioeconomic status, lack of consultation with a cardiologist, and cardiac rehabilitation following hospitalization were related to persistent smoking. Our findings may help develop strategies aimed at assisting smoking cessation in patients with CAD.