Comparing secondary prevention for patients with coronary heart disease and stroke attending Australian general practices: a cross-sectional study using nationwide electronic database.

OBJECTIVES: To compare secondary prevention care for patients with coronary heart disease (CHD) and stroke, exploring particularly the influences due to frequency and regularity of primary care visits. SETTING: Secondary prevention for patients (≥18 years) in the National Prescription Service administrative electronic health record database collated from 458 Australian general practice sites across all states and territories. DESIGN: Retrospective cross-sectional and panel study. Patient and care-level characteristics were compared for differing CHD/stroke diagnoses. Associations between the type of cardiovascular diagnosis and medication prescription as well as risk factor assessment were examined using multivariable logistic regression. PARTICIPANTS: Patients with three or more general practice encounters within 2 years of their latest visit during 2016-2020. OUTCOME MEASURES: Proportions and odds ratios (ORs) for (1) prescription of antihypertensives, antilipidaemics and antiplatelets and (2) assessment of blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) in patients with stroke only compared against those with CHD only and those with both conditions. RESULTS: There were 111 892 patients with CHD only, 27 863 with stroke only and 9791 with both conditions. Relative to patients with CHD, patients with stroke were underprescribed antihypertensives (70.8% vs 82.8%), antilipidaemics (63.1% vs 78.7%) and antiplatelets (42.2% vs 45.7%). With sociodemographic factors, comorbidities and level of care considered as covariates, the odds of non-prescription of any recommended secondary prevention medications were higher in patients with stroke only (adjusted OR 1.37; 95% CI (1.31, 1.44)) compared with patients with CHD only. Patients with stroke only were also more likely to have neither BP nor LDL-C monitored (adjusted OR 1.26; 95% CI (1.18, 1.34)). Frequent and regular general practitioner encounters were independently associated with the prescription of secondary prevention medications (p<0.001). CONCLUSIONS: Secondary prevention management is suboptimal in cardiovascular disease patients and worse post-stroke compared with post-CHD. More frequent and regular primary care encounters were associated with improved secondary prevention.

Engagement and fidelity of a cardiovascular disease prevention-focused digital health intervention in cardiology outpatient waiting rooms: a mixed-methods study.

INTRODUCTION: We delivered a video-based, cardiovascular disease prevention focused intervention in cardiology waiting rooms that increased motivation to improve cardiovascular risk behaviours and satisfaction with clinic services. To better understand the potential generalisability and scalability of such waiting room interventions, this study evaluated the fidelity of intervention delivery and barriers and enablers to implementation. METHODS: Mixed-methods process evaluation conducted among intervention participants in a randomised clinical trial. Data sources included (1) Participant screening logs, (2) Intervention delivery platform data and (3) Semi structured interviews performed with participants. Qualitative data were described using inductive thematic analysis. RESULTS: The tablet-based intervention was delivered to 220 patients (112 (50.9%) male, mean age 54.2 (SD 15.4) years). Of 765 videos opened, 636 (83.1%) were watched to completion. Most videos opened were rated (738/765, 96.5%) and video ratings were predominantly positive (661/738, (89.6%) satisfied or highly satisfied). Younger and more educated participants were more likely to rate videos highly (relative risk (RR) 1.73 (95% CI 1.28 to 2.32) and RR 1.26 (95% CI 1.07 to 1.49)) but less likely to watch videos to completion (younger: RR 0.27 (95% CI 0.17 to 0.43), more educated: RR 0.90 (95% CI 0.85 to 0.96)). Of 39 invited, 21 (53.8%) participated in semistructured interviews. Thematic analysis of responses suggested reported behaviour change post intervention may be due to increased awareness of cardiovascular risk, reduced anxiety and intrinsic motivation from delivery within a cardiology waiting room. Lack of reinforcement and limited personalisation were barriers. CONCLUSION: The current analysis demonstrates that engagement with a digitally delivered clinic waiting room educational intervention was high, providing explanation for its efficacy in improving motivation to change cardiovascular risk behaviours. The high fidelity of delivery demonstrates potential for scaling of such interventions across waiting rooms. Recall bias and low response rate may bias self-reported engagement measures. TRIAL REGISTRATION NUMBER: ANZCTR12618001725257.

Availability and affordability of medicines and cardiovascular outcomes in 21 high-income, middle-income and low-income countries.

OBJECTIVES: We aimed to examine the relationship between access to medicine for cardiovascular disease (CVD) and major adverse cardiovascular events (MACEs) among people at high risk of CVD in high-income countries (HICs), upper and lower middle-income countries (UMICs, LMICs) and low-income countries (LICs) participating in the Prospective Urban Rural Epidemiology (PURE) study. METHODS: We defined high CVD risk as the presence of any of the following: hypertension, coronary artery disease, stroke, smoker, diabetes or age >55 years. Availability and affordability of blood pressure lowering drugs, antiplatelets and statins were obtained from pharmacies. Participants were categorised: group 1-all three drug types were available and affordable, group 2-all three drugs were available but not affordable and group 3-all three drugs were not available. We used multivariable Cox proportional hazard models with nested clustering at country and community levels, adjusting for comorbidities, sociodemographic and economic factors. RESULTS: Of 163 466 participants, there were 93 200 with high CVD risk from 21 countries (mean age 54.7, 49% female). Of these, 44.9% were from group 1, 29.4% from group 2 and 25.7% from group 3. Compared with participants from group 1, the risk of MACEs was higher among participants in group 2 (HR 1.19, 95% CI 1.07 to 1.31), and among participants from group 3 (HR 1.25, 95% CI 1.08 to 1.50). CONCLUSION: Lower availability and affordability of essential CVD medicines were associated with higher risk of MACEs and mortality. Improving access to CVD medicines should be a key part of the strategy to lower CVD globally.

Environmental and societal influences acting on cardiovascular risk factors and disease at a population level: a review.

It has long been known that cardiovascular disease (CVD) rates vary considerably among populations, across space and through time. It is now apparent that most of the attributable risk for myocardial infarction 'within' populations from across the world can be ascribed to the varying levels of a limited number of risk factors among individuals in a population. Individual risk factors (e.g. blood pressure) can be modified with resulting health gains. Yet, the persistence of large international variations in cardiovascular risk factors and resulting CVD incidence and mortality indicates that there are additional factors that apply to 'populations' that are important to understand as part of a comprehensive approach to CVD control. This article reviews the evidence on why certain populations are more at risk than others.

Greater adverse effects of cholesterol and diabetes on carotid intima-media thickness in South Asian Indians: comparison of risk factor-IMT associations in two population-based surveys.

Asian Indians appear particularly susceptible to coronary heart disease compared with other ethnic groups. We compared the effects of vascular risk factors on carotid intima-media thickness (IMT) in a population of South Asians from Andhra Pradesh, India with a population of Caucasians from Perth, Australia. Cardiovascular risk factors and ultrasound-assessed carotid IMT were measured in randomly selected adults from two villages in rural India (n=303) and compared to those for randomly sampled adults from Australia (n=1111). Regression models with interaction terms were used to compare the strengths of associations between risk factors and carotid IMT, in these two populations. There were stronger associations of cholesterol (p for interaction=0.009) and diabetes (p=0.04) with carotid IMT in the Indian compared to the Australian population. Also, while increasing HDL-cholesterol was associated with decreasing carotid IMT in the Australian population the reverse was true for the Indian population (p<0.001). The associations with IMT of blood pressure, triglycerides, age, HDL to total cholesterol ratio, glucose, BMI, waist, waist to hip ratio and smoking were not different between the populations. Greater adverse effects of total cholesterol and diabetes on atherosclerosis and no protective effect of HDL-cholesterol amongst Asian Indians provide a novel possible explanation for observed excess rates of cardiovascular disease amongst these populations.

Significant lipid, adiposity and metabolic abnormalities amongst 4535 Indians from a developing region of rural Andhra Pradesh.

BACKGROUND AND OBJECTIVE: Both migrant and local urban populations of Asian Indians have high rates of cardiovascular disease. Metabolic risk factors appear key to this phenomenon but data from rural India are few. We sought to determine the prevalence and distribution of lipids, obesity and metabolic syndrome in a rural region of Andhra Pradesh. METHODS: Sampling was done in 20 villages representative of the project area with an age- and sex-stratified group of 4535 adults > or =30 years selected at random from a local census list. The sample represented 13% of all adults > or =30 years in the 20 villages with a response rate of 81%. All participants had interviewer administered questionnaire, physical examination and fasting finger-prick glucose. Every fourth individual had venous blood testing for lipid profile (n=1085). Analysis was done using weighting to obtain estimates of risk factor levels for the adult population in the 20 villages. In addition to standard WHO and 2005 NCEP-ATPIII classifications, exploratory 'Asian' definitions were used for overweight and abdominal obesity. RESULTS: The population mean levels of total, LDL, HDL-cholesterol and triglycerides were 4.5 (4.4-4.6) mmol/L, 2.8 (2.7-2.9) mmol/L, 1.1 (1.06-1.13) mmol/L, 1.5 (1.4-1.6) mmol/L for men; and 4.8 (4.7-4.9) mmol/L, 3.0 (3.0-3.1) mmol/L, 1.2 (1.16-1.22) mmol/L, 1.3 (1.2-1.4) mmol/L for women. 18.4% of men and 26.3% of women were overweight rising to 32.4% of men and 41.4% of women if 'Asian' definitions were used. Criteria for NCEP-ATPIII metabolic syndrome were met by 26.9% of men and 18.4% of women with figures of 32.5% and 23.9%, respectively, if 'Asian' waist cut-offs were substituted. CONCLUSIONS: Dyslipidaemia, adiposity and metabolic syndrome were common in this rural Indian population and prevalence was much greater if proposed Asian definitions for adiposity were used. Metabolic risk factors likely play a major role in cardiovascular disease in this region.

The role of the 12-lead ECG as a screening test for cardiac source of embolus.

BACKGROUND: Investigation for cardiac source of embolus (CSE) is one of the commonest referrals for transthoracic echocardiography (TTE) of hospital inpatients, but has a relatively low-diagnostic yield. We sort to investigate whether 12-lead ECG might be useful in screening patients to obviate the need for TTE, in a subset of patients referred for echocardiographic investigation of cardiac source of embolus. METHODS: We collected ECG and echo data for 400 consecutively referred inpatients for TTE investigation of possible cardiac source of embolus. We analysed this data for evidence of cardiac source of embolism on TTE in patients with a normal or abnormal ECG. RESULTS: 41/400 (10%) subjects had possible CSE identified on TTE. Diagnostic yield for CSE was higher for those with abnormal compared with normal ECG (17% versus 6%, p<0.001). Of 232/400 (58%) patients with a normal ECG, 200 had a normal TTE (86%). Of the 32 with normal ECG and abnormal TTE, echo found a possible embolic source in 13. Of those 168 (42%) with an abnormal ECG, TTE was normal in 73 and abnormal in 95, of whom 28 patients had an echo that identified a possible cardio-embolic source. ECG, therefore, had a sensitivity of 68%, specificity of 61%, positive predictive value of 0.17 and negative predictive value of 0.94 for detecting possible cardiac sources of embolus. CONCLUSIONS: Although TTE is a relatively low-yield investigation for the detection of cardiac source of embolus, 12-lead ECG is not sufficiently sensitive to identify the approximately 10% of patients in whom echo will demonstrate a diagnostic abnormality.