Performance of the SCORE and Globorisk cardiovascular risk prediction models: a prospective cohort study in Dutch general practice.

BACKGROUND: GPs frequently use 10-year-risk estimations of cardiovascular disease (CVD) to identify high- risk patients. AIM: To assess the performance of four models for predicting the 10-year risk of CVD in Dutch general practice. DESIGN AND SETTING: Prospective cohort study. Routine data (2009- 2019) was used from 46 Dutch general practices linked to cause of death statistics. METHOD: The outcome measures were fatal CVD for SCORE and first diagnosis of fatal or non- fatal CVD for SCORE fatal and non-fatal (SCORE- FNF), Globorisk-laboratory, and Globorisk-office. Model performance was assessed by examining discrimination and calibration. RESULTS: The final number of patients for risk prediction was 1981 for SCORE and SCORE-FNF, 3588 for Globorisk-laboratory, and 4399 for Globorisk- office. The observed percentage of events was 18.6% (n = 353) for SCORE- FNF, 6.9% (n = 230) for Globorisk-laboratory, 7.9% (n = 323) for Globorisk-office, and 0.3% (n = 5) for SCORE. The models showed poor discrimination and calibration. The performance of SCORE could not be examined because of the limited number of fatal CVD events. SCORE-FNF, the model that is currently used for risk prediction of fatal plus non-fatal CVD in Dutch general practice, was found to underestimate the risk in all deciles of predicted risks. CONCLUSION: Wide eligibility criteria and a broad outcome measure contribute to the model applicability in daily practice. The restriction to fatal CVD outcomes of SCORE renders it less usable in routine Dutch general practice. The models seriously underestimate the 10-year risk of fatal plus non-fatal CVD in Dutch general practice. The poor model performance is possibly because of differences between patients that are eligible for risk prediction and the population that was used for model development. In addition, selection of higher-risk patients for CVD risk assessment by GPs may also contribute to the poor model performance.

Screening for abdominal aortic aneurysm in patients with clinically manifest vascular disease.

AIMS: Declining prevalence of abdominal aortic aneurysm (AAA) might force a more targeted screening approach (high-risk populations only) in order to maintain (cost-)effectiveness. We aimed to determine temporal changes in the prevalence of screening-detected AAA, to assess AAA-related surgery, and evaluate all-cause mortality in patients with manifest vascular disease. METHODS AND RESULTS: We included patients with manifest vascular disease but without a history of AAA enrolled in the ongoing single-centre prospective UCC-SMART cohort study. Patients were screened at baseline for AAA by abdominal ultrasonography. We calculated sex- and age-specific prevalence of AAA, probability of survival in relation to the presence of AAA, and the proportion of patients undergoing AAA-related surgery. Prevalence of screening-detected AAA in 5440 screened men was 2.5% [95% confidence interval (CI) 2.1-2.9%] and in 1983 screened women 0.7% (95% CI 0.4-1.1%). Prevalence declined from 1997 until 2017 in men aged 70-79 years from 8.1% to 3.2% and in men aged 60-69 years from 5.7% to 1.0%. 36% of patients with screening-detected AAA received elective AAA-related surgery during follow-up (median time until surgery = 5.3 years, interquartile range 2.5-9.1). Patients with screening-detected AAA had a lower probability of survival (sex and age adjusted) compared to patients without screening-detected AAA (51%, 95% CI 41-64% vs. 69%, 95% CI 68-71%) after 15 years of follow-up. CONCLUSION: The prevalence of screening-detected AAA has declined over the period 1997-2017 in men with vascular disease but exceeds prevalence in already established screening programs targeting 65-year-old men. Screening for AAA in patients with vascular disease may be cost-effective, but this remains to be determined.

Blood pressure and cholesterol measurements in primary care: cross-sectional analyses in a dynamic cohort.

BACKGROUND: Guidelines on cardiovascular risk management (CVRM) recommend blood pressure (BP) and cholesterol measurements every 5 years in men aged ≥40 years and (post-menopausal) women aged ≥50 years. AIM: To evaluate CVRM guideline implementation. DESIGN & SETTING: Cross-sectional analyses in a dynamic cohort using primary care electronic health record (EHR) data from the Julius General Practitioners' Network (JGPN) (n = 388 929). METHOD: Trends (2008-2018) were assessed in the proportion of patients with at least one measurement (BP and cholesterol) every 1, 2, and 5 years, in those with:1. a history of cardiovascular disease (CVD) and diabetes mellitus (DM);2. a history of DM only;3. a history of CVD only;4. a cardiovascular risk assessment (CRA) indication based on other medical history, or;5. no CRA indication.Trends were evaluated over time using logistic regression mixed-model analyses. RESULTS: Trends in annual BP and cholesterol measurement increased for patients with a history of CVD from 37.0% to 48.4% (P<0.001) and 25.8% to 40.2% (P<0.001). In the 5-year window from 2014-2018, BP and cholesterol measurements were performed respectively in 78.5% and 74.1% of all men aged ≥40 years and 82.2% and 78.5% of all women aged ≥50 years. Least measured were patients without a CRA indication (men 60.2% and 62.4%; women 55.5% and 59.3%). CONCLUSION: The fairly high frequency of CVRM measurements available in the EHR of patients in primary care suggests an adequate implementation of the CVRM guideline. As nearly all individuals visit the GP at least once within a 5-year time window, improvement of CVRM remains possible, especially in those without a CRA indication.

Comorbidity in patients with cardiovascular disease in primary care: a cohort study with routine healthcare data.

BACKGROUND: Comorbidity is a major public health issue, which challenges health care configured around single diseases. AIM: To provide an overview of frequent disease combinations of one and two additional chronic diseases and groups among patients with cardiovascular disease (CVD) in general practice. DESIGN AND SETTING: Medical record data from the Julius General Practitioners' Network of 226 670 patients registered in 2015-2016 in Utrecht, the Netherlands, were collected and examined. METHOD: Prevalences and combinations of one and two comorbid conditions were determined, by age and sex, in four populations of patients with CVD: heart failure, peripheral arterial disease (PAD), coronary heart disease (CHD), or stroke. Using logistic regression analyses, the authors examined whether comorbid conditions were significantly more prevalent in patients with a specific cardiovascular condition compared with those without. RESULTS: Low vision, diabetes mellitus, back/neck problems, osteoarthritis, chronic obstructive pulmonary disease (COPD), and cancer were the most prevalent non-cardiovascular conditions and ranked in the top five of non-cardiovascular comorbid conditions in the different CVDs studied, irrespective of patient age and sex. Of these, diabetes, COPD, and low vision were statistically significantly more prevalent in all four cardiovascular conditions when compared with patients without the respective disease. Over the life span, the majority of the comorbid conditions were most prevalent in patients with heart failure, directly followed by those with PAD; they were less prevalent in patients with CHD and stroke. CONCLUSION: Comorbid conditions are very common in patients with CVD, even in younger age groups. To ensure efficient and effective treatment, organisational adaptations may be required in the healthcare system to accommodate comorbid conditions in patients with CVD.

Trends in comorbidity in patients hospitalised for cardiovascular disease.

BACKGROUND: We determined trends over time in cardiovascular and non-cardiovascular comorbidity in patients hospitalised for cardiovascular disease (CVD). METHODS: The Dutch nationwide hospital register was used to identify patients hospitalised for CVD during 2000-2010. Comorbidity was defined as a previous hospital admission for CVD other than the index CVD, cancer, diabetes, musculoskeletal and connective tissue disorders, respiratory disorders, thyroid gland disorders, kidney disorders and dementia in the five years previous to hospital admittance for the index CVD. Trends were calculated in strata of age and sex and for different types of CVD: coronary heart disease (CHD), cerebrovascular disease (CVA), heart failure (HF) and peripheral arterial disease (PAD). RESULTS: We identified 2,397,773 admissions for CVD between 2000 and 2010. Comorbidity was present in 38%. In HF, PAD, CHD and CVA this was 54%, 46%, 40%, and 32%, respectively. Between 2000 and 2010, the percentage of patients with comorbidity increased (+1.1%), this increase was most pronounced in patients ≥75years (+3.0%). Cardiovascular disease was the most frequent comorbid condition, though became less prevalent over time (men -5%; women: -2%), whereas non-cardiovascular comorbidity increased in men (+4%), and remained similar in women (-1%). Cancer was the most common non-cardiovascular comorbid condition and increased in men and women (men: +5%; women: +4%). CONCLUSIONS: Comorbid conditions are highly prevalent in patients hospitalised for CVD, especially HF and PAD patients. In older patients, prevalences increased over time. Cardiovascular diseases were the most common comorbid condition, though the prevalence decreased over the study period whereas the prevalence of cancer increased.

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

OBJECTIVE: We set out to determine what proportion of the mortality decline from 1997 to 2007 in coronary heart disease (CHD) in the Netherlands could be attributed to advances in medical treatment and to improvements in population-wide cardiovascular risk factors. METHODS: We used the IMPACT-SEC model. Nationwide information was obtained on changes between 1997 and 2007 in the use of 42 treatments and in cardiovascular risk factor levels in adults, aged 25 or over. The primary outcome was the number of CHD deaths prevented or postponed. RESULTS: The age-standardized CHD mortality fell by 48% from 269 to 141 per 100.000, with remarkably similar relative declines across socioeconomic groups. This resulted in 11,200 fewer CHD deaths in 2007 than expected. The model was able to explain 72% of the mortality decline. Approximately 37% (95% CI: 10%-80%) of the decline was attributable to changes in acute phase and secondary prevention treatments: the largest contributions came from treating patients in the community with heart failure (11%) or chronic angina (9%). Approximately 36% (24%-67%) was attributable to decreases in risk factors: blood pressure (30%), total cholesterol levels (10%), smoking (5%) and physical inactivity (1%). Ten% more deaths could have been prevented if body mass index and diabetes would not have increased. Overall, these findings did not vary across socioeconomic groups, although within socioeconomic groups the contribution of risk factors differed. CONCLUSION: CHD mortality has recently halved in The Netherlands. Equally large contributions have come from the increased use of acute and secondary prevention treatments and from improvements in population risk factors (including primary prevention treatments). Increases in obesity and diabetes represent a major challenge for future prevention policies.

Shifts in the age distribution and from acute to chronic coronary heart disease hospitalizations.

BACKGROUND: Shifts in the burden of coronary heart disease (CHD) from an acute to chronic illness have important public health consequences. OBJECTIVE: To assess age-sex-specific time trends in rates and characteristics of acute and chronic forms of CHD hospital admissions in the Netherlands. METHODS: Using nationwide Dutch registers, we assessed time trends between 1998 and 2007 in hospitalization rates of 188,266 acute myocardial infarction (AMI, ICD-9 410), 294,374 unstable angina (ICD-9 411, 413) and 205,649 chronic forms of CHD (ICD-9 412, 414) admissions. RESULTS: Between 1998 and 2007, the age-standardized CHD hospitalization rate declined from 688 to 545 per 100,000 in men and from 281 to 229 per 100,000 in women. Overall, hospitalization rates decreased at younger age (<75 years) but increased in very old age (≥85 years). The annual percentage change in hospitalization rates was larger for AMI (men:-5.1%, women:-4.4%) than for unstable angina patients (men:-2.0%, women:-2.0%). For chronic CHD, the average annual percentage change was +0.7% in men and +2.1% in women. The proportion of chronic CHD in the total of CHD admissions increased between 1998 and 2007 from 29% to 36% in men and from 23% to 30% in women. The proportion of AMI decreased from 30% to 24% in men and from 27% to 22% in women. CONCLUSIONS: An increasing proportion of Dutch CHD hospital admissions was for chronic forms of CHD. The age at hospitalization was pushed towards older age: premature CHD admission declined over time and admission rates at very old age increased.

Effect of including nonfatal events in cardiovascular risk estimation, illustrated with data from The Netherlands.

AIMS: European physicians use SCORE risk charts to predict a patient's 10-year risk of cardiovascular diseases (CVD) mortality. We examined whether the inclusion of nonfatal events improved risk estimation and the identification of high-risk persons. METHODS AND RESULTS: In the EPIC-NL cohort, risk factor data were collected between 1993 and 1997 in 6772 men and 9108 women aged 35-65 years. During 10 years of follow up, 540 total (fatal + nonfatal) CVD events occurred, of which 122 (23%) were fatal. Risk equations were developed using Cox proportional hazard models. Discriminating ability and hazard ratios for CVD risk factors did not differ between the two endpoints. Absolute risks for total CVD were approximately 4-fold higher than for CVD mortality. Using the current 5% CVD mortality threshold or the 22% total CVD threshold for identification of high-risk persons leaves more than 84% of all male and 98% of all female future cases untreated. Of those exceeding these thresholds, 20% and 27% of the men, respectively, and 16% and 19% of women will get a CVD event in the next 10 years. Cut-off points of 2% for CVD mortality, corresponding to 10% for total CVD, will identify high-risk persons of whom approximately 10% will get an event in the next 10 years. CONCLUSION: CVD mortality comprises a quarter of all total CVD events. Risk functions and the discriminating ability did not differ between the two endpoints. Cut-off points of 2% for CVD mortality or 10% for total CVD could be considered to identify high-risk persons.

Persisting gender differences and attenuating age differences in cardiovascular drug use for prevention and treatment of coronary heart disease, 1998-2010.

BACKGROUND: Evidence on recent time trends in age-gender differences in cardiovascular drug use is scarce. We studied time trends in age-gender-specific cardiovascular drug use for primary prevention, secondary prevention, and in-hospital treatment of coronary heart disease. METHODS AND RESULTS: The PHARMO database was used for record linkage of drug dispensing, hospitalization, and population data to identify drug use between 1998 and 2010 in 1 203 290 persons ≥25 years eligible for primary prevention, 84 621 persons hospitalized for an acute coronary syndrome (ACS), and 15 651 persons eligible for secondary prevention. The use of cardiovascular drugs increased over time in all three settings. In primary prevention, the proportion of women that used lipid-lowering drugs was lower than men between 2003 and 2010 (5.7 vs. 7.3% in 2010). The higher proportion of women that used blood pressure-lowering drugs for primary prevention, compared with men, attenuated over time (15.1 vs. 13.8% in 2010). During hospital admission for an ACS, the proportion of women that used cardiovascular drugs was lower than men. In secondary prevention (36 months after hospital discharge), drug use was lowest in young women. The proportion receiving lipid-lowering drugs declined after the age of 75 in all three settings. This age difference attenuated over time. CONCLUSION: Age differences in drug use tended to attenuate over time, whereas gender differences persisted. Areas potentially for improvement are in the hospital treatment of ACS in young women, in secondary prevention among young women and the elderly, and in the continuity of drug use in secondary prevention.

Population trends and inequalities in incidence and short-term outcome of acute myocardial infarction between 1998 and 2007.

OBJECTIVE: We studied time trends in acute myocardial infarction (AMI) incidence, including out-of-hospital mortality proportions and hospitalized case-fatality rates. In addition, we compared AMI trends by age, gender and socioeconomic status. METHODS: We linked the national Dutch hospital discharge register with the cause of death register to identify first AMI in patients ≥ 35 years between 1998 and 2007. Events were categorized in three groups: 178,322 hospitalized non-fatal, 43,210 hospitalized fatal within 28 days, and 75,520 out-of-hospital fatal AMI events. Time trends were analyzed using Joinpoint and Poisson regression. RESULTS: Since 1998, age-standardized AMI incidence rates decreased from 620 to 380 per 100,000 in 2007 in men and from 323 to 210 per 100,000 in 2007 in women. Out-of-hospital mortality decreased from 24.3% of AMI in 1998 to 20.6% in 2007 in men and from 33.0% to 28.9% in women. Hospitalized case-fatality declined from 2003 onwards. The annual percentage change in incidence was larger in men than women (-4.9% vs. -4.2%, P<0.001). Furthermore, the decline in AMI incidence was smaller in young (35-54 years: -3.8%) and very old (≥ 85 years: -2.6%) men and women compared to middle-aged individuals (55-84 years: -5.3%, P<0.001). Smaller declines in AMI rates were observed in deprived socioeconomic quintiles Q5 and Q4 relative to the most affluent quintile Q1 (P=0.002 and P=0.015). CONCLUSIONS: Substantial improvements were observed in incidence, out-of-hospital mortality and short-term case-fatality after AMI in the Netherlands. Young and female groups tend to fall behind, and socioeconomic inequalities in AMI incidence persisted and have not narrowed.