Prevalence of interarm blood pressure difference is notably higher in women; the Viborg population-based screening program (VISP).

BACKGROUND: Bilateral blood pressure (BP) measurement is important in cardiovascular prevention for identifying systolic interarm BP difference (IAD) and hypertension. We investigated sex-stratified IAD prevalence and its associations and coexistence with screen-detected peripheral atherosclerosis and hypertension. Furthermore, we determined the proportion misclassified as non-hypertensive when using the lower versus the higher reading arm. METHODS: This sub-study formed part of the Viborg Screening Program (VISP), a cross-sectorial population-based cardiovascular screening programme targeting 67-year-old Danes. VISP includes screening for peripheral atherosclerosis (lower extremity arterial disease and carotid plaque), abdominal aortic aneurysm, hypertension, diabetes mellitus, and cardiac disease. Self-reported comorbidities, risk factors, and medication use were also collected. Among 4,602 attendees, 4,517 (82.1%) had eligible bilateral and repeated BP measurements. IAD was defined as a systolic BP difference ≥ 10 mmHg. IAD-associated factors (screening results and risk factors) were estimated by logistic regression; proportional coexistence was displayed by Venn diagrams (screening results). RESULTS: We included 2,220 women (49.2%) and 2,297 men (50.8%). IAD was more predominant in women (26.8%) than men (21.0%) (p < 0.001). This disparity persisted after adjustment [odds ratio (OR) 1.53; 95% confidence interval (CI) 1.32-1.77]. No other association was recorded with the conditions screened for, barring potential hypertension: BP 140-159/90-99 mmHg (OR 1.68, 95% CI 1.44-1.97) and BP ≥ 160/100 mmHg (OR 1.82, 95% CI 1.49-2.23). Overall, IAD and BP ≥ 160/100 mmHg coexistence was 4% in women and 5% in men; for BP ≥ 140/90 mmHg, 13% and 14%, respectively. Among those recording a mean BP ≥ 140/90 mmHg in the higher reading arm, 14.5% of women and 15.3% of men would be misclassified as non-hypertensive compared with the lowest reading arm. CONCLUSION: Female sex was an independent factor of IAD prevalence but not associated with other arterial lesions. Approximately 15% needed reclassification according to BP ≥ 140/90 mmHg when the lower rather than the higher reading arm was used; verifying bilateral BP measurements improved detection of potential hypertension. In future, the predictive value of sex-stratified IAD should be assessed for cardiovascular events and death to verify its potential as a screening tool in population-based cardiovascular screening. TRIAL REGISTRATION FOR VISP: NCT03395509:10/12/2018.

Danish citizens' perspectives on the preventive medication recommended after screen-detected cardiovascular disease: A qualitative study.

BACKGROUND: The rationale for screening for cardiovascular disease (CVD) is debated as a prevention strategy. However, research shows that when preventive medication is initiated after screening for CVD, mortality rates decrease, especially among men. When implementing screening programmes, facilitating citizens' informed decisions and empowering their autonomy in the decision-making process are crucial. We therefore aimed to explore citizens' perspectives on and decisions regarding initiating cardiovascular preventive medication for screen-detected CVD. METHODS: We employed an exploratory qualitative design using semi-structured interviews to investigate participants' perspectives on and decisions regarding initiating cardiovascular preventive medication for screen-detected CVD. Twelve interviews were conducted and analysed using thematic analysis following Braun and Clarke's six-step approach. FINDINGS: We found one overall theme, Being on a continuum between wellness and illness, with two underlying sub-themes. Sub-theme (1) Navigating mixed feelings and pathways reflects participants' perspectives on CVD preventive medication, which were positioned on a continuum with shifting perspectives. The state between wellness and illness was experienced as liminal and characterised by uncertainty and concerns about CVD risk. (2) Navigating medication decisions: a negotiated process. Pivotal medical decisions hinged on trust in authorities or own judgement, influenced by attitudes towards the need for medication, perception of meaningfulness, asymptomatic condition, age, family responsibility and predisposition. Participants' medical decisions were supported and impacted by significant others. CONCLUSION: We uncovered a continuum of shifting perspectives ranging from feeling improved health to experiencing fear of CVD. For certain citizens, it is like navigating between these contrasting feelings. The perceived necessity and meaningfulness, in particular, shape medical decisions. Providing support for informed decisions is crucial and includes significant others. Shared decision-making with healthcare professionals as facilitators is needed. Future research is warranted to investigate how to embrace the various perspectives on initiating CVD preventive medication in clinical practice.

Adherence and Persistence to Antiplatelet Therapy in Lower Extremity Peripheral Arterial Disease: A Danish Population Based Cohort Study.

OBJECTIVE: Adherence to antiplatelet therapy is recommended but unexplored in patients with symptomatic lower extremity peripheral arterial disease (PAD). Therefore, this study aimed to determine adherence and persistence to antiplatelet therapy in patients with PAD, defined as intermittent claudication and chronic limb threatening ischaemia. DESIGN: Population based nationwide cohort study. METHODS: This study included all Danish citizens aged ≥ 40 years with a first inpatient or outpatient diagnosis of symptomatic PAD between 2010 - 2017, and who had at least one prescription claim for aspirin and/or clopidogrel within 90 days after diagnosis. Adherence was determined by the proportion of days covered (PDC) during the first year after diagnosis. Persistence was defined as no treatment gap ≥ 30 days between prescription renewals over three year follow up. RESULTS: A total of 39 687 patients were eligible for inclusion, of whom 23 279 (58.7%) claimed a prescription for aspirin and/or clopidogrel within 90 days of diagnosis. Among these, 12 898 (55.4%) were prevalent users, while the remainder comprised new users who initiated the therapy after the index PAD diagnosis. The mean PDC was 74.5% (SD 35.0%) for prevalent users and 60.5% (SD 30.5%) for new users. Adherence increased with age and number of concomitant drugs. The overall one year cumulative incidence treatment discontinuation was 13.0% (95% CI 12.5 - 13.4%) overall, 17.2% (CI 16.6 - 17.9%) for prevalent users, and 7.9% (CI 7.4 - 8.4%) for new users. At three year follow up, the cumulative incidence of discontinuation was 31.5% (CI 30.9 - 32.2%) overall, 44.6% (CI 43.7 - 45.4%) for prevalent users, and 14.6% (CI 13.9 - 15.3) for new users. CONCLUSION: Less than 60% of patients with newly diagnosed symptomatic PAD claimed a prescription for antiplatelet therapy within 90 days of diagnosis, and both adherence and persistence were moderate during the first year after diagnosis. These findings underscore the importance of efforts to improve the initiation and continuation of antiplatelet therapy in patients with PAD.

Relevance of the Viborg Population Based Screening Programme (VISP) for Cardiovascular Conditions Among 67 Year Olds: Attendance Rate, Prevalence, and Proportion of Initiated Cardiovascular Medicines Stratified By Sex.

OBJECTIVE: To report sex specific overall attendance rate, prevalence of screen detected cardiovascular conditions, proportion of unknown conditions before screening, and proportion initiating prophylactic medicine among 67 year olds in Denmark. DESIGN: Cross sectional cohort study. METHODS: Since 2014, all 67 year olds in Viborg, Denmark, have been invited to screening for abdominal aortic aneurysm (AAA), peripheral arterial disease (PAD), carotid plaque (CP), hypertension, cardiac disease, and type 2 diabetes. Individuals with AAA, PAD, and or CP are recommended cardiovascular prophylaxis. Combining data with registries has facilitated estimation of unknown screen detected conditions. Up to August 2019, 5 505 had been invited; registry data were available for the first 4 826 who were invited. RESULTS: The attendance rate was 83.7%, without sex difference. Screen detected prevalence was significantly lower among women than men: AAA, 5 (0.3%) vs. 38 (1.9%) (p < .001); PAD, 90 (4.5%) vs. 134 (6.6%) (p = .011); CP, 641 (31.8%) vs. 907 (44.8%) (p < .001); arrhythmia, 26 (1.4%) vs. 77 (4.2%) (p < .001); blood pressure ≥ 160/100 mmHg, 277 (13.8%) vs. 346 (17.1%) (p = .004); and HbA1c ≥ 48 mmol/mol, 155 (7.7%) vs. 198 (9.8%) (p = .019), respectively. Pre-screening proportions of unknown conditions were particularly high for AAA (95.4%) and PAD (87.5%). AAA, PAD, and or CP were found in 1 623 (40.2%), of whom 470 (29.0%) received pre-screening antiplatelets and 743 (45.8%) lipid lowering therapy. Furthermore, 413 (25.5%) started antiplatelet therapy and 347 (21.4%) started lipid lowering therapy. Only smoking was significantly associated with all vascular conditions in multivariable analysis: odds ratios (ORs) for current smoking were AAA 8.11 (95% CI 2.27 - 28.97), PAD 5.60 (95% CI 3.61 - 8.67) and CP 3.64 (95% CI 2.95 - 4.47). CONCLUSION: The attendance rate signals public acceptability for attending cardiovascular screening. Men had more screen detected conditions than women, but prophylactic medicine was started equally frequently in both sexes. Sex specific cost effectiveness follow up is warranted.

Gender-specific Predicted Normal Aortic Size and Its Consequences of the Population-Based Prevalence of Abdominal Aortic Aneurysms.

BACKGROUND: To investigate if a relative-size-index of the abdominal aortic diameter influences the prevalence estimates of abdominal aortic dilatations compared to absolute diameters. METHODS: Cross-sectional study. Participants from the Viborg Vascular Screening Trial, Viborg Women Cohort, and the Viborg Screening Program. Through multivariate linear regression analyses, 2 gender-specific prediction-equations were developed based upon body-surface area and age. The definitions of absolute and relative size of aortic ectasies were 25-29 mm and 1.25-1.49× individual-predicted size (IPS), abdominal aortic aneurysm (AAA) 30 mm and 1.5× IPS, and large repair-recommendable AAA ≥55 mm or ≥ 2.75× IPS, respectively. RESULTS: Nineteen thousand two hundred and sixty nine males (69.6 years) and 2,426 females (67.1 years) attended the population- and ultrasound-based screening studies for AAA. The mean peak systolic abdominal anterior-posterior inner to inner diameter was 19.1 mm (±5.3 mm) and 16.6 mm (±2.8 mm) (P < 0.001) in males and females, respectively. Body surface area showed the strongest correlation with aortic diameters in both males (r = 0.19, P < 0.001) and females (r = 0.17, P < 0.001). Age correlated significantly with size, but only in males (r = 0.03, P < 0.001). The prevalence in men of absolute size-defined and relative size index-defined screening-detected aortic ectasies, AAAs and repair-recommendable AAAs were: 5.9% and 9.5% (P < 0.001), 3.3% and 4.2% (P < 0.001) and 9.9% and 15.2% (P = 0.004), respectively. Prevalence in females of absolute-size-defined and relative-size-index-defined screening-detected aortic ectasies, AAAs and repair-recommendable AAAs were 1.2% and 5.8% (P < 0.001), 0.5% and 1.3% (P = 0.003) and 0.0% and 23.1% (P = 0.553), respectively. CONCLUSIONS: Despite statistical differences, ultrasound-based absolute diameters to detect AAA seem acceptable in men. In females, poor agreements were noticed concerning all 3 categories of aneurysms, indicating that the current absolute diagnostic cut-points do not reflect female anatomy.

Vitamin K2 Dependent Matrix Gla Protein Relating to Abdominal Aortic Aneurysm and Overall Mortality: A Combined Case Control and Cohort Study.

OBJECTIVE: Inactivation of matrix Gla protein (MGP), using vitamin K antagonists or vitamin K deficiency results in increased vascular calcification, which has been associated with increased risk of symptomatic or ruptured abdominal aortic aneurysm (AAA). Insufficient activation of MGP leads to increased levels of undercarboxylated forms of MGP, measured as a dephosphorylated, undercarboxylated MGP (dp-ucMGP) in plasma. This study aimed to investigate whether the level of inactivated MGP influenced the risk of having an AAA, the risk of AAA progression, and overall mortality. METHODS: This combined case control and cohort study was based on data from the randomised, clinically controlled Viborg Vascular (VIVA) screening trial. Cases (n = 487) with an AAA and controls (n = 189) with neither peripheral artery disease nor AAA, had their plasma quantified for dp-ucMGP. Plasma levels were compared with the presence of an AAA, AAA growth rate, need for repair, and overall mortality. dp-ucMGP was divided into tertiles in regression analyses. RESULTS: The plasma levels of dp-ucMGP were higher for AAA cases compared with controls (median of 517 pmol/L vs. 495 pmol/L, p = .036). Adjusted analyses regarding dp-ucMGP being predictive of AAA, AAA growth rate, and need for repair all failed to show correlation. Overall mortality for AAA cases exhibited a significant association for the third tertile of dp-ucMGP with a hazard ratio of 2.55 (95% CI 1.29 - 5.05) compared with the first tertile. Overall mortality for controls was not correlated with dp-ucMGP plasma levels. CONCLUSION: dp-ucMGP did not correlate with the risk of having an AAA, AAA growth rate, or risk of surgery. For people with an AAA, dp-ucMGP was correlated with an increased mortality risk for the highest tertile of dp-ucMGP. This could suggest a role for prophylactic measures with vitamin K2 supplements to people at risk of AAA.

Involving people with type 2 diabetes in facilitating participation in a cardiovascular screening programme.

BACKGROUND: Knowledge is lacking about how to increase uptake among people with type 2 diabetes (T2D) invited to preventive initiatives like cardiovascular screening. AIM: To explore how to improve participation of people with T2D in cardiovascular screening using patient and public involvement (PPI). METHODS: Patient and public involvement was included in a qualitative research design. From April to October 2019, we invited 40- to 60-year-old people with T2D (n = 17) to individual consultative meetings, using an interviewing approach. Before the interviews, participants were asked to read a proposed invitation letter to be used in a cardiovascular screening programme. Inductive content analysis was undertaken. RESULTS: Participants considered cardiovascular screening important and beneficial from both a personal and social perspective. We found that the relational interaction between the person with T2D and the health-care professional was key to participation and that nudging captured through the design of the screening programme and the wording of the invitation letter was requested. CONCLUSION: In preventive initiatives perceived as meaningful by the invitee, a focus on recruitment is crucial to facilitate participation. This study contributed with knowledge about how to promote participation by involving health-care professionals in recruitment initiatives and through nudging. This knowledge may assist researchers, policymakers and ethicists' understanding and assessment of the ethical appropriateness and public acceptability of nudging in cardiovascular screening. PATIENT OR PUBLIC CONTRIBUTION: By consulting 17 people with T2D, we are now in a position to suggest how a screening initiative should be altered because tools to improve uptake have been identified.

Eosinophils Protect Mice From Angiotensin-II Perfusion-Induced Abdominal Aortic Aneurysm.

RATIONALE: Blood eosinophil count and ECP (eosinophil cationic protein) associate with human cardiovascular diseases. Yet, whether eosinophils play a role in cardiovascular disease remains untested. The current study detected eosinophil accumulation in human and murine abdominal aortic aneurysm (AAA) lesions, suggesting eosinophil participation in this aortic disease. OBJECTIVE: To test whether and how eosinophils affect AAA growth. METHODS AND RESULTS: Population-based randomized clinically controlled screening trials revealed higher blood eosinophil count in 579 male patients with AAA than in 5063 non-AAA control (0.236±0.182 versus 0.211±0.154, 109/L, P<0.001). Univariate (odds ratio, 1.381, P<0.001) and multivariate (odds ratio, 1.237, P=0.031) logistic regression analyses indicated that increased blood eosinophil count in patients with AAA served as an independent risk factor of human AAA. Immunostaining and immunoblot analyses detected eosinophil accumulation and eosinophil cationic protein expression in human and murine AAA lesions. Results showed that eosinophil deficiency exacerbated AAA growth with increased lesion inflammatory cell contents, matrix-degrading protease activity, angiogenesis, cell proliferation and apoptosis, and smooth muscle cell loss using angiotensin-II perfusion-induced AAA in Apoe-/- and eosinophil-deficient Apoe-/-ΔdblGATA mice. Eosinophil deficiency increased lesion chemokine expression, muted lesion expression of IL (interleukin) 4 and eosinophil-associated-ribonuclease-1 (mEar1 [mouse EOS-associated-ribonuclease-1], human ECP homolog), and slanted M1 macrophage polarization. In cultured macrophages and monocytes, eosinophil-derived IL4 and mEar1 polarized M2 macrophages, suppressed CD11b+Ly6Chi monocytes, and increased CD11b+Ly6Clo monocytes. mEar1 treatment or adoptive transfer of eosinophil from wild-type and Il13-/- mice, but not eosinophil from Il4-/- mice, blocked AAA growth in Apoe-/-ΔdblGATA mice. Immunofluorescent staining and immunoblot analyses demonstrated a role for eosinophil IL4 and mEar1 in blocking NF-κB (nuclear factor-κB) activation in macrophages, smooth muscle cells, and endothelial cells. CONCLUSIONS: Eosinophils play a protective role in AAA by releasing IL4 and cationic proteins such as mEar1 to regulate macrophage and monocyte polarization and to block NF-κB activation in aortic inflammatory and vascular cells.

Magnetic resonance imaging of the intraluminal thrombus in abdominal aortic aneurysms: a quantitative and qualitative evaluation and correlation with growth rate.

BACKGROUND: The role of the intraluminal thrombus (ILT) in abdominal aortic aneurysm (AAA) growth remains incompletely understood. MRI is superior to other methods in depicting the morphology of the ILT. This study brings preliminary, but novel information on the presence and morphological characteristics of the ILT and AAA growth rates in a screening cohort. METHODS: Cohort study with 46 patients from the Viborg Vascular Trial. All underwent one non-contrast-enhanced magnetic resonance imaging (MRI) at the end of follow-up. ILT presence was noted and, if present, it was allocated to one of four morphological categories based on visual appearance and signal intensity on T2 weighted images. RESULTS: The mean growth rate was 1.95 mm/year ±0.87 (SD). The observation time was 5.59±0.63 (SD) years. ILT was present in AAA size groups as follows: 30-34.9 mm 20.00%, 35-39.9 mm 88.89%, 40-44.9 mm 81.25%, 45-49.9 mm 100% and 50-54.9 mm 100%. Out of 46, 8 had no ILT at the time of MRI. The presence of any sort of ILT yielded a significantly increased unadjusted and an adjusted growth rate of 1.09 mm/year (95% CI: 0.48; 1.70) and 1.24 mm/year (95% CI: 0.64; 1.83), respectively. All four thrombus types were retrospectively associated with an increased recorded growth rate compared with "no thrombus". Presence of a thin circumferential thrombus was retrospectively associated with the highest increase in growth rate, viz. 2.09 mm/year (95% CI: 1.23; 2.95). CONCLUSIONS: We observed faster growth rate in those AAA that had developed an ILT. Even faster growth was observed amongst those AAA containing a thin ILT located along the inner circumference.

Effectiveness of Screening Postmenopausal Women for Cardiovascular Diseases: A Population Based, Prospective Parallel Cohort Study.

OBJECTIVES: To investigate the effectiveness of systematic screening for multifaceted cardiovascular disease (CVD) in postmenopausal women on all cause mortality and, secondarily, on CVD morbidity. Effectiveness was also evaluated across age strata. METHODS: This was a population based, prospective, parallel cohort study. In total, 107,491 women born in 1936-1951 living in the Central Denmark region were identified in the Danish Civil Registration System. From this population, all women born in 1936, 1941, 1946, and 1951 (n = 1984) living in the Viborg municipality were invited to attend screening. Of those invited to the screening, 1474 (74.3%) attended. The control group included all women from the general population born in 1936-1951 and living in the Central Denmark Region, excluding those invited for the screening. Information on medication and comorbidities prior to inclusion and study outcomes were retrieved from national registries for both groups. The screening included examination for abdominal aortic aneurysm (AAA), peripheral arterial disease (PAD), carotid plaque (CP), potential hypertension (HT), atrial fibrillation (AF), diabetes mellitus (DM), and dyslipidaemia. The adjusted Cox proportional hazards model with the intention to screen principle was used to assess effectiveness for the total population and across age groups. RESULTS: During follow up (median 3.3 years, IQR 2.9-3.9), the adjusted hazard ratios (HRs) for invited versus controls were the following: all cause mortality, 0.89 (95% CI 0.71-1.12); myocardial infarction (MI), 1.26 (95% CI 0.52-3.07); ischaemic heart disease (IHD), 0.72 (95% CI 0.49-1.05); PAD, 1.07 (95% CI 0.49-2.31); and ischaemic stroke, 1.20 (95% CI 0.78-1.85). A substantial number of women with AAA, PAD, and/or CP declined prophylactic therapy: 45% for antiplatelet and 35% for cholesterol lowering agents. CONCLUSIONS: This multifaceted screening offer to a general population sample of postmenopausal women had no effects on all cause mortality or hospital admission for MI, IHD, PAD, and stroke within a short-term follow up period.

A population-based screening study for cardiovascular diseases and diabetes in Danish postmenopausal women: acceptability and prevalence.

BACKGROUND: Reducing women's cardiovascular risk and the economic costs associated with cardiovascular diseases (CVD) and diabetes (DM) continues to be a challenge. Whether a multifaceted CVD screening programme is beneficial as a preventive strategy in women remains uncertain. The aim of this study was to investigate the prevalence of CVD and DM as well as the acceptability toward screening and preventive actions. METHODS: An observational study was performed among all women born in 1936, 1941, 1946 and 1951 living in Viborg Municipality, Denmark, from October 2011. In total, 1984 were invited to screening for abdominal aortic aneurysm (AAA), peripheral arterial disease (PAD), carotid plaque (CP), hypertension (HT), atrial fibrillation (AF), DM and dyslipidaemia. Participants with positive tests were offered prophylactic intervention including follow-up consultations in case of AAA, PAD and/or CP. Participants with AAA ≥ 50 mm were referred to specialists in vascular surgery. Women with AF or potential familial hypercholesterolaemia (FH) were referred to cardiology work-up. RESULTS: Among those invited, 1474 (74.3%) attended screening, but the attendees' share decreased with increasing age groups (p < 0.001). AAA was diagnosed in 10 (0.7%) women, PAD in 101 (6.9%) and CP in 602 (40.8%). The percentage of women with these conditions rose with increasing age group (p < 0.05). Unconfirmed potential HT was observed in 94 (6.4%), unknown AF in 6 (0.4%), DM in 14 (1%) and potential FH in 35 (2.4%). None of these findings differed across age groups. Among the 631 women diagnosed with AAA, PAD and/or CP, 182 (28.8%) were already in antiplatelet and 223 (35.3%) in lipid-lowering therapy prior to screening. Antiplatelet therapy was initiated in 215 (34.1%) and lipid-lowering therapy in 191 (30.3%) women. Initiation of antiplatelet and lipid-lowering therapy was further recommended to 134 (21.2%) and 141 (22.4%) women, respectively, who hesitated to follow the recommendation. CONCLUSIONS: The study recorded an acceptable total attendance rate, even though a significantly lower attendance rate was observed in the eldest women. The identified hesitation towards prophylactic therapy may affect the rationale and effectiveness of CVD screening, and hesitation seems a critical issue that should be addressed in the design of future screening programmes.

Effect of Impulsive Compression Treatment on Postoperative Complications After Open Peripheral Vascular Revascularization (In Situ): Protocol for a Randomized Control Trial.

BACKGROUND: In patients with critical leg ischemia (CLI), the standard operative choice is an in situ bypass to the lower extremity to improve the patients´ prognosis and quality of life. Postoperative complications after surgery occur in 18 % of the patients, prolonging hospitalization and convalescence. The main operative complication is edema. This can be prevented by early mobilization or stimulation of the natural venous pump in the leg. OBJECTIVE: To investigate whether compression therapy with foot pump reduces postoperative edema, facilitates wound healing of the operation wounds, promotes healing of ischemic ulcers, and shortens hospitalization, increasing and improving the patient's subjective quality of life faster. METHODS: The protocol is designed as a randomized, unblinded prospective study with 50 patients in each group. Standard postoperative routines after bypass surgery, including short-stretch bandaging of the operated legs, are compared to supportive stimulation of the venous pump by an impulsive compression foot pump. The postoperative edema of the leg is measured 10 cm below the patella and 8 cm proximal to the medial malleolus. Measurements are performed preoperatively, 1 and 4 days postoperatively and at discharge. RESULTS: The primary endpoint is reduction of leg edema by at least 50%. The secondary endpoint includes earlier mobilization in the pump group and decreased length of stay in hospital. Quality of life is evaluated through the European Health Related Quality of Life Questionnaire 5 Dimensions (EQ-5D) and Vascular Quality of Life Questionnaire-6 (VascuQol-6) questionnaires. The start of the study is February 1, 2018, and the end of the study is February 1, 2020. First results will be available April 2020. CONCLUSIONS: In orthopedic surgery of the lower extremities, the use of foot pumps has shown a reduction of edema and thrombosis in risk patients. Although important positive effects may be expected after vein bypass surgery, no reports have yet investigated the use of the device in vascular-operated patients and no analysis or meta Cochrane reviews are available in this field. TRIAL REGISTRATION: ClinicalTrials.gov NCT03192982; https://clinicaltrials.gov/ct2/show/NCT03192982 (Archived by WebCite at http://www.webcitation.org/6xMZJ06dw).

An interview-based study of nonattendance at screening for cardiovascular diseases and diabetes in older women: Nonattendees' perspectives.

AIMS AND OBJECTIVES: This study explored nonattendees' perspectives on a screening programme for cardiovascular disease and diabetes mellitus among women aged 60-77 years. BACKGROUND: Nonattendance in screening is a common concern and has been associated with increased morbidity and mortality. Whether nonattendees need targeted information to participate in screening is unknown. Thus, it is important to explore the reasons for nonattendance, particularly as nonattendees' perspectives have not been fully explored. DESIGN: An interview study. METHODS: The data were obtained through semistructured interviews with 10 women sampled from a population who declined to participate in a women's screening programme for cardiovascular disease and diabetes mellitus. Additionally, reflective notes on the interview context were documented. The data were collected in 2013. Kvale and Brinkmann's method for data analysis was applied. RESULTS: All informants found the screening offer personally irrelevant, but this belief was changeable. The informants' perceptions of screening were based on subjective health and risk beliefs, personal knowledge of diseases and the screening programme, and distrust in the healthcare system. CONCLUSION: Personal experiences, beliefs and self-protective strategies influence individuals' subjective interpretations of a screening programme's relevance. The perception that screening is irrelevant seems to be rooted in nonattendees' personal health-related assessment and knowledge. Consequently, whether nonattendance is determined by an informed decision is questionable. Negative experiences with the healthcare system led to hesitation towards screening in general. RELEVANCE TO CLINICAL PRACTICE: This study is relevant to healthcare workers as well as decision-makers from a screening and preventive perspective. The findings highlight important issues that should be addressed to encourage invitees to accept screening invitations and to facilitate informed decision-making about screening participation.

Glycated Hemoglobin Is Associated With the Growth Rate of Abdominal Aortic Aneurysms: A Substudy From the VIVA (Viborg Vascular) Randomized Screening Trial.

OBJECTIVE: An inverse association between abdominal aortic aneurysms (AAAs) and diabetes mellitus exists; however, the cause remains unknown. This study aimed to evaluate whether the degree of glycemia is associated with aneurysm growth. APPROACH AND RESULTS: The study was based on VIVA trial (Viborg Vascular), the randomized clinically controlled screening trial for abdominal aortic aneurysm in men aged 65 to 74 years in the Central Denmark Region. The screening included measurement of the abdominal aorta by ultrasound, analysis of glycated hemoglobin (HbA1c), and follow-up for ≤5 years for aneurysms <5 cm. Analyses were conducted using mixed-effect models. At baseline, VIVA screening identified 619 individuals (3.3%) with abdominal aortic aneurysms. A total of 103 individuals were referred for vascular evaluation, and after removal of additional individuals who were lost to follow-up or had missing blood samples, we were left with 319 individuals. Sixty-one individuals (19.1%) had diabetes mellitus. The median growth rate was 1.7 versus 2.7 mm/y in individuals with and without diabetes mellitus, respectively (P<0.001). We found a significant inverse association between aneurysmal growth rate and HbA1c in the total study population (P=0.002). Both crude and adjusted analyses identified slower growth for the group with the highest HbA1c tertile compared with the lowest HbA1c tertile. After 3 years, the mean difference was 1.8 mm (confidence interval, 0.98-2.64). Similar significant differences were observed in subgroup analysis of individuals without self-reported diabetes mellitus. CONCLUSIONS: We found an inverse association between the growth rate of abdominal aortic aneurysms and the level of HbA1c, indicating that long-lasting elevated blood sugar impairs aneurysmal progression in individuals with and without known diabetes mellitus.