European Society of Cardiology: the 2023 Atlas of Cardiovascular Disease Statistics.

This report from the European Society of Cardiology (ESC) Atlas Project updates and expands upon the 2021 report in presenting cardiovascular disease (CVD) statistics for the ESC member countries. This paper examines inequalities in cardiovascular healthcare and outcomes in ESC member countries utilizing mortality and risk factor data from the World Health Organization and the Global Burden of Disease study with additional economic data from the World Bank. Cardiovascular healthcare data were collected by questionnaire circulated to the national cardiac societies of ESC member countries. Statistics pertaining to 2022, or latest available year, are presented. New material in this report includes contemporary estimates of the economic burden of CVD and mortality statistics for a range of CVD phenotypes. CVD accounts for 11% of the EU's total healthcare expenditure. It remains the most common cause of death in ESC member countries with over 3 million deaths per year. Proportionately more deaths from CVD occur in middle-income compared with high-income countries in both females (53% vs. 34%) and males (46% vs. 30%). Between 1990 and 2021, median age-standardized mortality rates (ASMRs) for CVD decreased by median >50% in high-income ESC member countries but in middle-income countries the median decrease was <12%. These inequalities between middle- and high-income ESC member countries likely reflect heterogeneous exposures to a range of environmental, socioeconomic, and clinical risk factors. The 2023 survey suggests that treatment factors may also contribute with middle-income countries reporting lower rates per million of percutaneous coronary intervention (1355 vs. 2330), transcatheter aortic valve implantation (4.0 vs. 153.4) and pacemaker implantation (147.0 vs. 831.9) compared with high-income countries. The ESC Atlas 2023 report shows continuing inequalities in the epidemiology and management of CVD between middle-income and high-income ESC member countries. These inequalities are exemplified by the changes in CVD ASMRs during the last 30 years. In the high-income ESC member countries, ASMRs have been in steep decline during this period but in the middle-income countries declines have been very small. There is now an important need for targeted action to reduce the burden of CVD, particularly in those countries where the burden is greatest.

Impact of the COVID-19 pandemic on delayed care of cardiovascular diseases in Europe: a systematic review.

BACKGROUND: Cardiovascular diseases remain the foremost global cause of death. The COVID-19 pandemic has strained health-care systems, leading to delays in essential medical services, including treatment for cardiovascular diseases. We aimed to examine the impact of the pandemic on delayed cardiovascular care in Europe. METHODS: In this systematic review, we searched PubMed, Embase, and Web of Science for peer-reviewed and published quantitative studies in English from Nov 1, 2019, to Sept 18, 2022, that addressed pandemic-induced delays in cardiovascular disease care for adult patients in Europe. Data appraisal, extraction, and quality assessment were done by two reviewers using the 14-item QualSyst tool checklist. We extracted summary patient-level data from the studies, including around 3·5 million patients. Evaluated outcomes included changes pre-March 2020 and during the COVID-19 pandemic in hospital admissions, mortality rates, medical help-seeking delays post-symptom onset, treatment initiation delays, and treatment procedure counts. The protocol is registered on PROSPERO (CRD42022354443). FINDINGS: Of the 132 included studies (20% from the UK), all were observational retrospective, with 87% focusing on the first wave of the pandemic. Results were categorised into five disease groups: ischaemic heart diseases, cerebrovascular diseases, cardiac arrests, heart failures, and others. Hospital admissions showed significant decreases around the ranges of 12-66% for ischaemic heart diseases, 9-40% for cerebrovascular diseases, 9-66% for heart failures, 27-88% for urgent and elective cardiac procedures, and an increase between 11-56% for cardiac arrests. Mortality rates were significantly higher during the pandemic, ranging between 1-25% (vs 16-22% before the pandemic) for ischaemic heart diseases and 8-70% (vs 8-26% before the pandemic) for cerebrovascular diseases. Only one study ranked low in quality. INTERPRETATION: The pandemic led to reduced acute CVD hospital admissions and increased mortality rates. Delays in seeking medical help were observed, while urgent and elective cardiac procedures decreased. Policymakers and health-care systems should work together on implementing adequate resource allocation strategies and clear guidelines on how to handle care during health crises, reducing diagnosis and treatment initiation delays, and promoting a healthy lifestyle. Future studies should evaluate the long-term impact of pandemics on delayed CVD care, and the health-economic impact of COVID-19. FUNDING: Belgian Science Policy Office.

The Cost of Atrial Fibrillation: A Systematic Review.

OBJECTIVES: Atrial fibrillation (AF) is the most common cardiac arrhythmia, with an increasing incidence and prevalence because of progressively aging populations. Costs related to AF are both direct and indirect. This systematic review aims to identify the main cost drivers of the illness, assess the potential economic impact resulting from changes in care strategies, and propose interventions where they are most needed. METHODS: A systematic literature search of the PubMed and Scopus databases was performed to identify analytical observational studies defining the cost of illness in cases of AF. The search strategy was based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 recommendations. RESULTS: Of the 944 articles retrieved, 24 met the inclusion criteria. These studies were conducted in several countries. All studies calculated the direct medical costs, whereas 8 of 24 studies assessed indirect costs. The median annual direct medical cost per patient, considering all studies, was €9409 (13 333 US dollars in purchasing power parities), with a very large variability due to the heterogeneity of different analyses. Hospitalization costs are generally the main cost drivers. Comorbidities and complications, such as stroke, considerably increase the average annual direct medical cost of AF. CONCLUSIONS: In most of the analyzed studies, inpatient care cost represents the main component of the mean direct medical cost per patient. Stroke and heart failure are responsible for a large share of the total costs; therefore, implementing guidelines to manage comorbidities in AF is a necessary step to improve health and mitigate healthcare costs.

The health and economic burden of musculoskeletal disorders in Belgium from 2013 to 2018.

INTRODUCTION: Low back pain (LBP), neck pain (NKP), osteoarthritis (OST) and rheumatoid arthritis (RHE) are among the musculoskeletal (MSK) disorders causing the greatest disability in terms of Years Lived with Disability. The current study aims to analyze the health and economic impact of these MSK disorders in Belgium, providing a summary of morbidity and mortality outcomes from 2013 to 2018, as well as direct and indirect costs from 2013 to 2017. METHODS: The health burden of LBP, NKP, OST and RHE in Belgium from 2013 to 2018 was summarized in terms of prevalence and disability-adjusted life years (DALY) using data from the Belgian health interview surveys (BHIS), the INTEGO database (Belgian registration network for general practitioners) and the Global Burden of Diseases study 2019. The economic burden included estimates of direct medical costs and indirect costs, measured by cost of work absenteeism. For this purpose, data of the respondents to the BHIS-2013 were linked with the national health insurance data (intermutualistic agency [IMA] database) 2013-2017. RESULTS: In 2018, 2.5 million Belgians were affected by at least one MSK disorder. OST represented the disorder with the highest number of cases for both men and women, followed by LBP. In the same year, MSK disorders contributed to a total of 180,746 DALYs for female and 116,063 DALYs for men. LBP appeared to be the largest contributor to the health burden of MSK. Having at least one MSK disorder costed on average 3 billion € in medical expenses and 2 billion € in indirect costs per year, with LBP being the most costly. CONCLUSION: MSK disorders represent a major health and economic burden in Belgium. As their burden will probably continue to increase in the future, acting on the risk factors associated to these disorders is crucial to mitigate both the health and economic burden.

European Society of Cardiology: cardiovascular disease statistics 2021.

AIMS: This report from the European Society of Cardiology (ESC) Atlas Project updates and expands upon the widely cited 2019 report in presenting cardiovascular disease (CVD) statistics for the 57 ESC member countries. METHODS AND RESULTS: Statistics pertaining to 2019, or the latest available year, are presented. Data sources include the World Health Organization, the Institute for Health Metrics and Evaluation, the World Bank, and novel ESC sponsored data on human and capital infrastructure and cardiovascular healthcare delivery. New material in this report includes sociodemographic and environmental determinants of CVD, rheumatic heart disease, out-of-hospital cardiac arrest, left-sided valvular heart disease, the advocacy potential of these CVD statistics, and progress towards World Health Organization (WHO) 2025 targets for non-communicable diseases. Salient observations in this report: (i) Females born in ESC member countries in 2018 are expected to live 80.8 years and males 74.8 years. Life expectancy is longer in high income (81.6 years) compared with middle-income (74.2 years) countries. (ii) In 2018, high-income countries spent, on average, four times more on healthcare than middle-income countries. (iii) The median PM2.5 concentrations in 2019 were over twice as high in middle-income ESC member countries compared with high-income countries and exceeded the EU air quality standard in 14 countries, all middle-income. (iv) In 2016, more than one in five adults across the ESC member countries were obese with similar prevalence in high and low-income countries. The prevalence of obesity has more than doubled over the past 35 years. (v) The burden of CVD falls hardest on middle-income ESC member countries where estimated incidence rates are ∼30% higher compared with high-income countries. This is reflected in disability-adjusted life years due to CVD which are nearly four times as high in middle-income compared with high-income countries. (vi) The incidence of calcific aortic valve disease has increased seven-fold during the last 30 years, with age-standardized rates four times as high in high-income compared with middle-income countries. (vii) Although the total number of CVD deaths across all countries far exceeds the number of cancer deaths for both sexes, there are 15 ESC member countries in which cancer accounts for more deaths than CVD in males and five-member countries in which cancer accounts for more deaths than CVD in females. (viii) The under-resourced status of middle-income countries is associated with a severe procedural deficit compared with high-income countries in terms of coronary intervention, ablation procedures, device implantation, and cardiac surgical procedures. CONCLUSION: Risk factors and unhealthy behaviours are potentially reversible, and this provides a huge opportunity to address the health inequalities across ESC member countries that are highlighted in this report. It seems clear, however, that efforts to seize this opportunity are falling short and present evidence suggests that most of the WHO NCD targets for 2025 are unlikely to be met across ESC member countries.

The non-fatal burden of cancer in Belgium, 2004-2019: a nationwide registry-based study.

BACKGROUND: The importance of assessing and monitoring the health status of a population has grown in the last decades. Consistent and high quality data on the morbidity and mortality impact of a disease represent the key element for this assessment. Being increasingly used in global and national burden of diseases (BoD) studies, the Disability-Adjusted Life Year (DALY) is an indicator that combines healthy life years lost due to living with disease (Years Lived with Disability; YLD) and due to dying prematurely (Years of Life Lost; YLL). As a step towards a comprehensive national burden of disease study, this study aims to estimate the non-fatal burden of cancer in Belgium using national data. METHODS: We estimated the Belgian cancer burden from 2004 to 2019 in terms of YLD, using national population-based cancer registry data and international disease models. We developed a microsimulation model to translate incidence- into prevalence-based estimates, and used expert elicitation to integrate the long-term impact of increased disability due to surgical treatment. RESULTS: The age-standardized non-fatal burden of cancer increased from 2004 to 2019 by 6 and 3% respectively for incidence- and prevalence-based YLDs. In 2019, in Belgium, breast cancer had the highest morbidity impact among women, followed by colorectal and non-melanoma skin cancer. Among men, prostate cancer had the highest morbidity impact, followed by colorectal and non-melanoma skin cancer. Between 2004 and 2019, non-melanoma skin cancer significantly increased for both sexes in terms of age-standardized incidence-based YLD per 100,000, from 49 to 111 for men and from 15 to 44 for women. Important decreases were seen for colorectal cancer for both sexes in terms of age-standardized incidence-based YLD per 100,000, from 105 to 84 for men and from 66 to 58 for women. CONCLUSIONS: Breast and prostate cancers represent the greatest proportion of cancer morbidity, while for both sexes the morbidity burden of skin cancer has shown an important increase from 2004 onwards. Integrating the current study in the Belgian national burden of disease study will allow monitoring of the burden of cancer over time, highlighting new trends and assessing the impact of public health policies.

Validity of self-reported air pollution annoyance to assess long-term exposure to air pollutants in Belgium.

In epidemiological studies, assessment of long term exposure to air pollution is often estimated using air pollution measurements at fixed monitoring stations, and interpolated to the residence of survey participants through Geographical Information Systems (GIS). However, obtaining georeferenced address data from national registries requires a long and cumbersome administrative procedure, since this kind of personal data is protected by privacy regulations. This paper aims to assess whether information collected in health interview surveys, including air pollution annoyance, could be used to build prediction models for assessing individual long term exposure to air pollution, removing the need for data on personal residence address. Analyses were carried out based on data from the Belgian Health Interview Survey (BHIS) 2013 linked to GIS-modelled air pollution exposure at the residence place of participants older than 15 years (n = 9347). First, univariate linear regressions were performed to assess the relationship between air pollution annoyance and modelled exposure to each air pollutant. Secondly, a multivariable linear regression was performed for each air pollutant based on a set of variables selected with elastic net cross-validation, including variables related to environmental annoyance, socio-economic and health status of participants. Finally, the performance of the models to classify individuals in three levels of exposure was assessed by means of a confusion matrix. Our results suggest a limited validity of self-reported air pollution annoyance as a direct proxy for air pollution exposure and a weak contribution of environmental annoyance variables in prediction models. Models using variables related to the socio-economic status, region, urban level and environmental annoyance allow to predict individual air pollution exposure with a percentage of error ranging from 8% to 18%. Although these models do not provide very accurate predictions in terms of absolute exposure to air pollution, they do allow to classify individuals in groups of relative exposure levels, ranking participants from low over medium to high air pollution exposure. This model represents a rapid assessment tool to identify groups within the BHIS participants undergoing the highest levels of environmental stress.

The impact of multimorbidity patterns on health-related quality of life in the general population: results of the Belgian Health Interview Survey.

BACKGROUND: Chronic diseases and multimorbidity are a major cause of disease burden-for patients, caregivers, and society. Little is known however about potential interaction effects between specific disease combinations. Besides an additive effect, the presence of multiple conditions could also act synergistically or antagonistically regarding the impact on patients' health-related quality of life (HRQoL). The aim was to estimate the impact of coexisting chronic diseases on HRQoL of the adult general Belgian population. METHODS: The Belgian Health Interview Survey 2018 provided data on self-reported chronic conditions and HRQoL (EQ-5D-5L) for a nationally representative sample. Linear mixed models were used to analyze two-way and three-way interactions of disease combinations on HRQoL. RESULTS: Multimorbidity had a prevalence of 46.7% (≥ 2 conditions) and 29.7% (≥ 3 conditions). HRQoL decreased considerably with the presence of multiple chronic diseases. 14 out of 41 dyad combinations and 5 out of 13 triad combinations showed significant interactions, with a dominant presence of negative/synergistic effects. Positive/antagonistic effects were found in more subjective chronic diseases such as depression and chronic fatigue. Conditions appearing the most frequently in significant disease pair interactions were dorsopathies, respiratory diseases, and arthropathies. CONCLUSIONS: Diverse multimorbidity patterns, both dyads and triads, were synergistically or antagonistically associated with lower HRQoL. Tackling the burden of multimorbidity is needed, especially because most disease combinations affect each other synergistically, resulting in a greater reduction in HRQoL. Further knowledge about those multimorbidity patterns with a greater impact on HRQoL is needed to better understand disease burden beyond mortality and morbidity data.

Belgian population norms for the EQ-5D-5L, 2018.

PURPOSE: Health-related quality of life outcomes are increasingly used to monitor population health and health inequalities and to assess the (cost-) effectiveness of health interventions. The EQ-5D-5L has been included in the Belgian Health Interview Survey, providing a new source of population-based self-perceived health status information. This study aims to estimate Belgian population norms for the EQ-5D-5L by sex, age, and region and to analyze its association with educational attainment. METHODS: The BHIS 2018 provided EQ-5D-5L data for a nationally representative sample of the Belgian population. The dimension scores and index values were analyzed using logistic and linear regressions, respectively, accounting for the survey design. RESULTS: More than half of respondents reported problems of pain/discomfort, while over a quarter reported problems of anxiety/depression. The average index value was 0.84. Women reported more problems on all dimensions, but particularly on anxiety/depression and pain/discomfort, resulting in significantly lower index values. Problems with mobility, self-care, and usual activities showed a sharp increase after the age of 80 years. Consequently, index values decreased significantly by age. Lower education was associated with a higher prevalence of problems for all dimensions except anxiety/depression and with a significantly lower index value. CONCLUSION: This paper presents the first nationally representative Belgian population norms using the EQ-5D-5L. Inclusion of the EQ-5D in future surveys will allow monitoring over time of self-reported health, disease burden, and health inequalities.

QALY losses for chronic diseases and its social distribution in the general population: results from the Belgian Health Interview Survey.

BACKGROUND: The burden of chronic diseases is rapidly rising, both in terms of morbidity and mortality. This burden is disproportionally carried by socially disadvantaged population subgroups. Quality-adjusted life years (QALYs) measure the impact of disease on mortality and morbidity into a single index. This study aims to estimate the burden of chronic diseases in terms of QALY losses and to model its social distribution for the general population. METHODS: The Belgian Health Interview Survey 2013 and 2018 provided data on self-reported chronic conditions for a nationally representative sample. The annual QALY loss per 100,000 individuals was calculated for each condition, incorporating disease prevalence and health-related quality of life (HRQoL) data (EQ-5D-5L). Socioeconomic inequalities, based on respondents' socioeconomic status (SES), were assessed by estimating population attributable fractions (PAF). RESULTS: For both years, the largest QALY losses were observed in dorsopathies, arthropathies, hypertension/high cholesterol, and genitourinary problems. QALY losses were larger in women and in older individuals. Individuals with high SES had consistently lower QALY loss when facing a chronic disease compared to those with low SES. In both years, a higher PAF was found in individuals with hip fracture and stroke. In 2013, the health inequality gap amounts to 33,731 QALYs and further expanded to 42,273 QALYs in 2018. CONCLUSION: Given that chronic diseases will rise in the next decades, addressing its burden is necessary, particularly among the most vulnerable (i.e. older persons, women, low SES). Interventions in these target groups should get priority in order to reduce the burden of chronic diseases.

Health care costs and lost productivity costs related to excess weight in Belgium.

BACKGROUND: This study aimed to estimate annual health care and lost productivity costs associated with excess weight among the adult population in Belgium, using national health data. METHODS: Health care costs and costs of absenteeism were estimated using data from the Belgian national health interview survey (BHIS) 2013 linked with individual health insurance data (2013-2017). Average yearly health care costs and costs of absenteeism were assessed by body mass index (BMI) categories - i.e., underweight (BMI < 18.5 kg/m2), normal weight (18.5 ≤ BMI < 25 kg/m2), overweight (25 ≤ BMI < 30 kg/m2) and obesity (BMI ≥ 30 kg/m2). Health care costs were also analysed by type of cost (i.e. ambulatory, hospital, reimbursed medication). The cost attributable to excess weight and the contribution of various other chronic conditions to the incremental cost of excess weight were estimated using the method of recycled prediction (a.k.a. standardisation). RESULTS: According to BHIS 2013, 34.7% and 13.9% of the Belgian adult population were respectively affected by overweight or obesity. They were mostly concentrated in the age-group 35-65 years and had significantly more chronic conditions compared to the normal weight population. Average total healthcare expenses for people with overweight and obesity were significantly higher than those observed in the normal weight population. The adjusted incremental annual health care cost of excess weight in Belgium was estimated at €3,329,206,657 (€651 [95% CI: €144-€1,084] and €1,015 [95% CI: €343-€1,697] per capita for individuals with overweight and obesity respectively). The comorbidities identified to be the main drivers for these incremental health care costs were hypertension, high cholesterol, serious gloom and depression. Mean annual incremental cost of absenteeism for overweight accounted for €242 per capita but was not statistically significant, people with obesity showed a significantly higher cost (p < 0.001) compared to the normal weight population: €2,015 [95% CI: €179-€4,336] per capita. The annual total incremental costs due to absenteeism of the population affected by overweight and obesity was estimated at €1,209,552,137. Arthritis, including rheumatoid arthritis and osteoarthritis, was the most important driver of the incremental cost of absenteeism in individuals with overweight and obesity, followed by hypertension and low back pain. CONCLUSIONS: The mean annual incremental cost of excess weight in Belgium is of concern and stresses the need for policy actions aiming to reduce excess body weight. This study can be used as a baseline to evaluate the potential savings and health benefits of obesity prevention interventions.

Polypharmacy and Health-Related Quality of Life/Psychological Distress Among Patients With Chronic Disease.

INTRODUCTION: To date, no study has investigated the impact of polypharmacy (use of ≥5 medications concurrently) on health-related quality of life (HRQOL) and psychological distress in a combined sample of chronic disease patients and patients with multimorbidity, using diverse HRQOL measures. This study aimed to explore the association between polypharmacy and HRQOL/psychological distress by using data from a cross-sectional study in Flanders (Belgium). METHODS: We analyzed cross-sectional survey data on 544 chronically ill patients recruited from June 2019 through June 2021. HRQOL was measured with the EuroQol-5 Dimension-5 Level questionnaire (EQ-5D-5L) and the 12-Item Short Form Health Survey (SF-12); psychological distress was measured with the Hospital Anxiety and Depression Scale (HADS). Multiple linear regression models were built to assess the association between polypharmacy and HRQOL/psychological distress. RESULTS: Overall, compared with patients without polypharmacy, patients with polypharmacy reported worse EQ-5D-5L index values, EuroQol visual analogue scale (EQ-VAS) scores, SF-12 physical component scores (PCS), SF-12 mental component scores (MCS), and HADS anxiety and depression subscales. In the final regression model adjusting for age, sex, educational attainment, and multimorbidity, polypharmacy remained significantly associated with lower HRQOL in terms of the EQ-5D-5L index (ß = -0.12; P = .008), EQ-VAS (ß = -0.11; P = .01), and SF-12 PCS (ß = -0.15; P = .002) but not with psychological distress (HADS) and SF-12 MCS. CONCLUSION: This study found that polypharmacy was negatively associated with the physical domain of HRQOL, but not with the mental domain, among patients with chronic diseases. These results may be especially important for patients with multimorbidity, given their greater risk of polypharmacy.

Cost-Effectiveness of COVID-19 Policy Measures: A Systematic Review.

OBJECTIVES: The COVID-19 pandemic has had a major impact on our society, with drastic policy restrictions being implemented to contain the spread of the severe acute respiratory syndrome coronavirus 2. This study aimed to provide an overview of the available evidence on the cost-effectiveness of various coronavirus disease 2019 policy measures. METHODS: A systematic literature search was conducted in PubMed, Embase, and Web of Science. Health economic evaluations considering both costs and outcomes were included. Their quality was comprehensively assessed using the Consensus Health Economic Criteria checklist. Next, the quality of the epidemiological models was evaluated. RESULTS: A total of 3688 articles were identified (March 2021), of which 23 were included. The studies were heterogeneous with regard to methodological quality, contextual factors, strategies' content, adopted perspective, applied models, and outcomes used. Overall, testing/screening, social distancing, personal protective equipment, quarantine/isolation, and hygienic measures were found to be cost-effective. Furthermore, the most optimal choice and combination of strategies depended on the reproduction number and context. With a rising reproduction number, extending the testing strategy and early implementation of combined multiple restriction measures are most efficient. CONCLUSIONS: The quality assessment highlighted numerous flaws and limitations in the study approaches; hence, their results should be interpreted with caution because the specific context (country, target group, etc) is a key driver for cost-effectiveness. Finally, including a societal perspective in future evaluations is key because this pandemic has an indirect impact on the onset and treatment of other conditions and on our global economy.

Medical Treatment in Coronary Patients: Is there Still a Gender Gap? Results from European Society of Cardiology EUROASPIRE V Registry.

PURPOSE: This study is aimed at investigating gender differences in the medical management of patients with coronary heart disease (CHD). METHODS: Analyses were based on the ESC EORP EUROASPIRE V (European Survey Of Cardiovascular Disease Prevention And Diabetes) survey. Consecutive patients between 18 and 80 years, hospitalized for a coronary event, were included in the study. Information on cardiovascular medication intake at hospital discharge and at follow-up (≥ 6 months to < 2 years after hospitalization) was collected. RESULTS: Data was available for 8261 patients (25.8% women). Overall, no gender differences were observed in the prescription and use of cardioprotective medication like aspirin, beta-blockers, and ACE-I/ARBs (P > 0.01) at discharge and follow-up respectively. However, a statistically significant difference was found in the use of statins at follow-up, in disfavor of women (82.8% vs. 77.7%; P < 0.001). In contrast, at follow-up, women were more likely to use diuretics (31.5% vs. 39.5%; P < 0.001) and calcium channel blockers (21.2% vs. 28.8%; P < 0.001), whereas men were more likely to use anticoagulants (8.8% vs. 7.0%; P < 0.001). Overall, no gender differences were found in total daily dose intake (P > 0.01). Furthermore, women were less likely than men to have received a CABG (20.4% vs. 13.2%; P < 0.001) or PCI (82.1% vs. 74.9%; P < 0.001) at follow-up. No gender differences were observed in prescribed (P = 0.10) and attended (P = 0.63) cardiac rehabilitation programs. CONCLUSION: The EUROASPIRE V results show only limited gender differences in the medical management of CHD patients. Current findings suggest growing awareness about risk in female CHD patients.

Sexual counselling in patients with heart failure: Perceptions and current practice by healthcare providers in Flanders.

BACKGROUND: Although heart failure (HF) patients often consider sexual activity as an essential aspect of their quality of life (QoL) and are usually uncertain if it is safe to perform sexual activity, this topic is overall poorly addressed in clinical practice. AIMS: The aim of this study was to explore the perceptions and practices of Flemish caregivers. METHODS: Healthcare providers were recruited through convenience sampling and filled in an adapted version of the UNITE Sexual Counselling Instrument. Several relevant network structures in Flanders were used to distribute the questionnaires-online as well as on paper-to healthcare workers being involved in the care to HF patients. RESULTS: Results of 180 participants indicated that 51.5% of the healthcare providers have never provided sexual counselling in HF patients. Being male, having a masters' degree, having more than 10 years of experience in cardiovascular disease, working in an ambulatory care department and having more positive attitudes were independently associated with a higher provision of sexual counselling in practice. CONCLUSION: Although healthcare providers perceive it as their responsibility to discuss patients' sexual concerns, these issues are not often addressed in daily practice. Increasing knowledge in healthcare providers and specific practical training in providing information on sexual activity in HF patients are recommended. Further studies are needed to investigate how sexual counselling can be provided in agreement with HF patients' expectations and needs.

Living with a chronic disease: insights from patients with a low socioeconomic status.

BACKGROUND: Little is known about how patients with low socioeconomic status (SES) experience their chronic disease, and how it impacts health-related quality of life (HRQoL). Compared to their more affluent counterparts, worse outcomes have been reported. A better understanding of the domains of HRQoL that are relevant to these specific populations is therefore needed. We explored the experiences of living with a chronic disease in low SES persons. METHODS: A qualitative interview study was performed in Flanders, Belgium. Semi-structured interviews were conducted in chronically ill patients, selected through purposive sampling. Interviews were audio-recorded and transcribed verbatim. Analysis followed an inductive and iterative approach. RESULTS: Fifteen patients were interviewed. Six major themes were identified: a heavy bag to carry, loss of autonomous life, inner and outer loneliness, emotional imbalance, unmet need for support, and coping strategies. Patients experienced their illness as an additional problem on top of all other problems (i.e. financial/social problems, traumatic life events). In general, the disease burden and non-disease burden were mutually reinforcing, resulting in greater dependency, greater risk of social isolation, greater psychological distress, and greater risk of impaired HRQoL. CONCLUSIONS: This study is the first to provide detailed insight into the experiences of living with a chronic disease in low SES persons. A conceptual model is proposed that can be used in daily clinical practice to raise awareness among clinicians and health care providers that the patient's needs go beyond the disease itself. Future research is needed to validate and test the model.

European Society of Cardiology: Cardiovascular Disease Statistics 2019.

AIMS: The 2019 report from the European Society of Cardiology (ESC) Atlas provides a contemporary analysis of cardiovascular disease (CVD) statistics across 56 member countries, with particular emphasis on international inequalities in disease burden and healthcare delivery together with estimates of progress towards meeting 2025 World Health Organization (WHO) non-communicable disease targets. METHODS AND RESULTS: In this report, contemporary CVD statistics are presented for member countries of the ESC. The statistics are drawn from the ESC Atlas which is a repository of CVD data from a variety of sources including the WHO, the Institute for Health Metrics and Evaluation, and the World Bank. The Atlas also includes novel ESC sponsored data on human and capital infrastructure and cardiovascular healthcare delivery obtained by annual survey of the national societies of ESC member countries. Across ESC member countries, the prevalence of obesity (body mass index ≥30 kg/m2) and diabetes has increased two- to three-fold during the last 30 years making the WHO 2025 target to halt rises in these risk factors unlikely to be achieved. More encouraging have been variable declines in hypertension, smoking, and alcohol consumption but on current trends only the reduction in smoking from 28% to 21% during the last 20 years appears sufficient for the WHO target to be achieved. The median age-standardized prevalence of major risk factors was higher in middle-income compared with high-income ESC member countries for hypertension {23.8% [interquartile range (IQR) 22.5-23.1%] vs. 15.7% (IQR 14.5-21.1%)}, diabetes [7.7% (IQR 7.1-10.1%) vs. 5.6% (IQR 4.8-7.0%)], and among males smoking [43.8% (IQR 37.4-48.0%) vs. 26.0% (IQR 20.9-31.7%)] although among females smoking was less common in middle-income countries [8.7% (IQR 3.0-10.8) vs. 16.7% (IQR 13.9-19.7%)]. There were associated inequalities in disease burden with disability-adjusted life years per 100 000 people due to CVD over three times as high in middle-income [7160 (IQR 5655-8115)] compared with high-income [2235 (IQR 1896-3602)] countries. Cardiovascular disease mortality was also higher in middle-income countries where it accounted for a greater proportion of potential years of life lost compared with high-income countries in both females (43% vs. 28%) and males (39% vs. 28%). Despite the inequalities in disease burden across ESC member countries, survey data from the National Cardiac Societies of the ESC showed that middle-income member countries remain severely under-resourced compared with high-income countries in terms of cardiological person-power and technological infrastructure. Under-resourcing in middle-income countries is associated with a severe procedural deficit compared with high-income countries in terms of coronary intervention, device implantation and cardiac surgical procedures. CONCLUSION: A seemingly inexorable rise in the prevalence of obesity and diabetes currently provides the greatest challenge to achieving further reductions in CVD burden across ESC member countries. Additional challenges are provided by inequalities in disease burden that now require intensification of policy initiatives in order to reduce population risk and prioritize cardiovascular healthcare delivery, particularly in the middle-income countries of the ESC where need is greatest.

EQ-5D in coronary patients: what are they suffering from? Results from the ESC EORP European Survey of Cardiovascular Disease Prevention and Diabetes (EUROASPIRE IV) Registry.

OBJECTIVE: Coronary patients often suffer from an impaired health, hence the aim of this study is to assess how coronary patients score on the different EQ-5D dimensions. METHODS: Analyses are based on the EUROASPIRE IV survey, conducted across 24 European countries. 7567 patients with stable coronary heart disease (mean age = 64.1 (SD = 9.6); males = 75.8%) completed the EQ-5D-5L instrument, 6 months to 3 years after their index hospitalization. Descriptive statistics and multilevel logistic regression was used to assess the differences between patient groups in reported problems on the EQ-5D dimensions. Furthermore, age-standardized country-specific outcomes were reported. RESULTS: About one out of four patients reported to have no problems on all five dimensions (57.9% reported no problems on mobility, 88.4% reported no problems on self-care, 67.1% reported no problems on usual activities, 41.1% reported no problems on pain/discomfort, and 56.2% reported no problems on anxiety/depression). Elderly patients and females reported more problems. Patients with behavioral risk factors and patients with comorbidities were more likely to have severe or extreme problems. Comparison across countries showed major differences in reported problems. CONCLUSIONS: Whether or not coronary patients have problems on one or more EQ-5D dimension, as well as the severity of the problems reported is largely associated with the patient profile. The least problems are seen on the self-care dimension and most problems are reported on the pain/discomfort dimension.

The relationship of nursing home price and quality of life.

BACKGROUND: Knowledge about the relationship between the residents' Quality of Life (QOL) and the nursing home price is currently lacking. Therefore, this study investigates the relationship between 11 dimensions of QOL and nursing homes price in Flemish nursing homes. METHODS: The data used in this cross-sectional study were collected by the Flemish government from years 2014 to 2017 and originates from 659 Flemish nursing homes. From 2014 to 2016, data on the QOL of 21,756 residents was assessed with the InterRAI instrument. This instrument contains 11 QOL dimensions. Multiple linear regression analyses were conducted to examine the research question. RESULTS: The multiple linear regressions indicated that a 10 euro increase in the daily nursing home price is associated with a significant decrease (P <  0.001) of 0.1 in 5 dimensions of QOL (access to services, comfort and environment, food and meals, respect, and safety and security). Hence, our results indicate that the association between price and QOL is very small. When conducting a subgroup analysis based on ownership type, the earlier found results remained only statistically significant for private nursing homes. CONCLUSION: Our findings show that nursing home price is of limited importance with respect to resident QOL. Contrary to popular belief, our study demonstrates a limited negative effect of price on QOL. Further research that includes other indicators of QOL is needed to allow policymakers and nursing home managers to improve nursing home residents' QOL.

Incidence of cardiovascular events in patients with stabilized coronary heart disease: the EUROASPIRE IV follow-up study.

The EUROASPIRE surveys (EUROpean Action on Secondary Prevention through Intervention to Reduce Events) demonstrated that most European coronary patients fail to achieve lifestyle, risk factor and therapeutic targets. Here we report on the 2-year incidence of hard cardiovascular (CV) endpoints in the EUROASPIRE IV cohort. EUROASPIRE IV (2012-2013) was a large cross-sectional study undertaken at 78 centres from selected geographical areas in 24 European countries. Patients were interviewed and examined at least 6 months following hospitalization for a coronary event or procedure. Fatal and non-fatal CV events occurring at least 1 year after this baseline screening were registered. The primary outcome in our analyses was the incidence of CV death or non-fatal myocardial infarction, stroke or heart failure. Cox regression models, stratified for country, were fitted to relate baseline characteristics to outcome. Our analyses included 7471 predominantly male patients. Overall, 222 deaths were registered of whom 58% were cardiovascular. The incidence of the primary outcome was 42 per 1000 person-years. Comorbidities were strongly and significantly associated with the primary outcome (multivariately adjusted hazard ratio HR, 95% confidence interval): severe chronic kidney disease (HR 2.36, 1.44-3.85), uncontrolled diabetes (HR 1.89, 1.50-2.38), resting heart rate ≥ 75 bpm (HR 1.74, 1.30-2.32), history of stroke (HR 1.70, 1.27-2.29), peripheral artery disease (HR 1.48, 1.09-2.01), history of heart failure (HR 1.47, 1.08-2.01) and history of acute myocardial infarction (HR 1.27, 1.05-1.53). Low education and feelings of depression were significantly associated with increased risk. Lifestyle factors such as persistent smoking, insufficient physical activity and central obesity were not significantly related to adverse outcome. Blood pressure and LDL-C levels appeared to be unrelated to cardiovascular events irrespective of treatment. In patients with stabilized CHD, comorbid conditions that may reflect the ubiquitous nature of atherosclerosis, dominate lifestyle-related and other modifiable risk factors in terms of prognosis, at least over a 2-year follow-up period.