Baseline findings of the population-based, randomized, multifaceted Danish cardiovascular screening trial (DANCAVAS) of men aged 65-74 years.

BACKGROUND: The challenge of managing age-related diseases is increasing; routine checks by the general practitioner do not reduce cardiovascular mortality. The aim here was to reduce cardiovascular mortality by advanced population-based cardiovascular screening. The present article reports the organization of the study, the acceptability of the screening offer, and the relevance of multifaceted screening for prevention and management of cardiovascular disease. METHODS: Danish men aged 65-74 years were invited randomly (1 : 2) to a cardiovascular screening examination using low-dose non-contrast CT, ankle and brachial BP measurements, and blood tests. RESULTS: In all, 16 768 of 47 322 men aged 65-74 years were invited and 10 471 attended (uptake 62·4 per cent). Of these, 3481 (33·2 per cent) had a coronary artery calcium score above 400 units. Thoracic aortic aneurysm was diagnosed in the ascending aorta (diameter 45 mm or greater) in 468 men (4·5 per cent), in the arch (at least 40 mm) in 48 (0·5 per cent) and in the descending aorta (35 mm or more) in 233 (2·2 per cent). Abdominal aortic aneurysm (at least 30 mm) and iliac aneurysm (20 mm or greater) were diagnosed in 533 (5·1 per cent) and 239 (2·3 per cent) men respectively. Peripheral artery disease was diagnosed in 1147 men (11·0 per cent), potentially uncontrolled hypertension (at least 160/100 mmHg) in 835 (8·0 per cent), previously unknown atrial fibrillation confirmed by ECG in 50 (0·5 per cent), previously unknown diabetes mellitus in 180 (1·7 per cent) and isolated severe hyperlipidaemia in 48 men (0·5 per cent). In all, 4387 men (41·9 per cent), excluding those with potentially uncontrolled hypertension, were referred for additional cardiovascular prevention. Of these, 3712 (35·5 per cent of all screened men, but 84·6 per cent of those referred) consented and were started on medication. CONCLUSION: Multifaceted cardiovascular screening is feasible and may optimize cardiovascular disease prevention in men aged 65-74 years. Uptake is lower than in aortic aneurysm screening.

Cost-effectiveness of population-based vascular disease screening and intervention in men from the Viborg Vascular (VIVA) trial.

BACKGROUND: Population-based screening and intervention for abdominal aortic aneurysm, peripheral artery disease and hypertension was recently reported to reduce the relative risk of mortality among Danish men by 7 per cent. The aim of this study was to investigate the cost-effectiveness of vascular screening versus usual care (ad hoc primary care-based risk assessment) from a national health service perspective. METHODS: A cost-effectiveness evaluation was conducted alongside an RCT involving all men from a region in Denmark (50 156) who were allocated to screening (25 078) or no screening (25 078) and followed for up to 5 years. Mobile nurse teams provided screening locally and, for individuals with positive test results, referrals were made to general practices or hospital-based specialized centres for vascular surgery. Intention-to-treat-based, censoring-adjusted incremental costs (2014 euros), life-years and quality-adjusted life-years (QALYs) were estimated using Lin's average estimator method. Incremental net benefit was estimated using Willan's estimator and sensitivity analyses were conducted. RESULTS: The cost of screening was estimated at €148 (95 per cent c.i. 126 to 169), and the effectiveness at 0·022 (95 per cent c.i. 0·006 to 0·038) life-years and 0·069 (0·054 to 0·083) QALYs, generating average costs of €6872 per life-year and €2148 per QALY. At a willingness-to-pay threshold of €40 000 per QALY, the probabilities of cost-effectiveness were 98 and 99 per cent respectively. The probability of cost-effectiveness was 71 per cent when all the sensitivity analyses were combined into one conservative scenario. CONCLUSION: Vascular screening appears to be cost-effective and compares favourably with current screening programmes.

The DanCavas Pilot Study of Multifaceted Screening for Subclinical Cardiovascular Disease in Men and Women Aged 65-74 Years.

OBJECTIVE/BACKGROUND: This pilot study of a large population based randomised screening trial investigated feasibility, acceptability, and relevance (prevalence of clinical and subclinical cardiovascular disease [CVD] and proportion receiving insufficient prevention) of a multifaceted screening for CVD. METHODS: In total, 2060 randomly selected Danish men and women aged 65-74 years were offered (i) low dose non-contrast computed tomography to detect coronary artery calcification (CAC) and aortic/iliac aneurysms; (ii) detection of atrial fibrillation (AF); (iii) brachial and ankle blood pressure measurements; and (iv) blood levels of cholesterol and hemoglobin A1c. Web based self booking and data management was used to reduce the administrative burden. RESULTS: Attendance rates were 64.9% (n = 678) and 63.0% (n = 640) for men and women, respectively. In total, 39.7% received a recommendation for medical preventive actions. Prevalence of aneurysms was 12.4% (95% confidence interval [CI] 9.9-14.9) in men and 1.1% (95% CI 0.3-1.9) in women, respectively (p < .001). A CAC score > 400 was found in 37.8% of men and 11.3% of women (p < .001), along with a significant increase in median CAC score with age (p = .03). Peripheral arterial disease was more prevalent in men (18.8%, 95% CI 15.8-21.8) than in women (11.2%, 95% CI 8.7-13.6). No significant differences between the sexes were found with regard to newly discovered AF (men 1.3%, women 0.5%), potential hypertension (men 9.7%, women 11.5%), hypercholesterolemia (men 0.9%, women 1.1%) or diabetes mellitus (men 2.1%, women 1.3%). CONCLUSION: Owing to the higher prevalence of severe conditions, such as aneurysms and CAC ≥ 400, screening for CVD seemed more prudent in men than women. The attendance rates were acceptable compared with other screening programs and the logistical structure of the screening program proved successful.

Five-year outcomes following a randomized trial of femorofemoral and femoropopliteal bypass grafting with heparin-bonded or standard polytetrafluoroethylene grafts.

BACKGROUND: Cohort studies suggest superior long-term patency of luminal heparin-bonded polytetrafluoroethylene (Hb-PTFE) bypass grafts compared with standard PTFE grafts. The aim of this study was to compare the outcomes of Hb-PTFE grafts with those of standard PTFE grafts 5 years after a randomized trial. METHODS: Patients with intermittent claudication or critical limb ischaemia requiring femorofemoral or femoropopliteal bypass grafting were randomized in a clinical trial of Hb-PTFE versus standard PTFE in 11 Scandinavian centres between 2005 and 2009. Patients were followed up for 5 years with clinical assessment and surveillance Duplex ultrasound imaging. The primary endpoint of this study was primary patency. Secondary endpoints included major amputation and mortality. RESULTS: Overall, 569 patients were enrolled in the randomized trial. Some 552 had follow-up data available for analysis of the primary outcome. Use of Hb-PTFE significantly improved patency by 37 per cent at 2 years, but 5 years after randomization there was no difference in primary patency (adjusted hazard ratio (HR) 0·95, 95 per cent c.i. 0·71 to 1·28; P = 0·748). In patients with critical limb ischaemia the use of Hb-PTFE reduced the 5-year risk of loss of primary patency by 37 per cent (HR 0·63, 0·40 to 0·99; P = 0·049). CONCLUSION: In this study there was no difference in primary graft patency between Hb-PTFE and standard PTFE grafts. Patients receiving Hb-PTFE grafts for critical limb ischaemia were more likely to have a patent graft at 5 years than those with standard PTFE grafts.

Animal Models Used to Explore Abdominal Aortic Aneurysms: A Systematic Review.

OBJECTIVE: Experimental animal models have been used to investigate the formation, development, and progression of abdominal aortic aneurysms (AAAs) for decades. New models are constantly being developed to imitate the mechanisms of human AAAs and to identify treatments that are less risky than those used today. However, to the authors' knowledge, there is no model identical to the human AAA. The objective of this systematic review was to assess the different types of animal models used to investigate the development, progression, and treatment of AAA and to highlight their advantages and limitations. METHODS: A search protocol was used to perform a systematic literature search of PubMed and Embase. A total of 2,830 records were identified. After selection of the relevant articles, 564 papers on animal AAA models were included. RESULTS: The most common models in rodents, including elastase, calcium chloride, angiotensin II, xenograft, and transgenic models, and the most common models in non-rodents, including chemically induced, graft models, and patch models, all have limitations with regard to the pathological interpretation of human AAA. CONCLUSION: Although findings from animal models of AAAs cannot be directly translated to human AAAs, the identification and awareness of animal models of AAA will provide knowledge for further investigation and insight into human AAA disease.

Editor's Choice - High Heritability of Liability to Abdominal Aortic Aneurysms: A Population Based Twin Study.

OBJECTIVE: First degree relatives of patients with abdominal aortic aneurysm (AAA) have an increased risk of developing AAA; however, despite intensive investigation, the specific genetic factors involved in the development of the disease are still largely unknown. In twin studies the influence of genetic and environmental factors can be assessed by comparing concordance rates between monozygotic (MZ) and dizygotic (DZ) twins. Higher phenotypic similarity between MZ than DZ twins indicates a genetic attribution to the etiology. The objective of this study was to investigate the heritability of AAA among Danish twins using concordance rates and heritability estimates. METHODS: The Danish Twin Registry was used to identify all Danish twin pairs (born 1880-1971) where both twins were alive on January 1, 1977. AAA cases were then identified using the National Patient Registry and the Registry of Cause of Death. Probandwise concordance rates were calculated and heritability estimated using structural equation modeling. RESULTS: The study identified 414 twins with AAA; 69.8% (289/414) were men and 30.2% (125/414) women. The probandwise concordance rate in MZ twins was 30% (95% CI 20.3-43.3%) compared with 12% (95% CI 7.0-20.1%) in DZ twins. In the heritability analysis 77% (95% CI 67-85%) of the total variance was explained by additive genetic components and 23% (95% CI 15-33%) was explained by non-shared environmental factors. CONCLUSIONS: The probandwise concordance rate was found to be 2.5 times higher in MZ compared with DZ twins. An overall heritability of 77% was determined.

Baseline prevalence of abdominal aortic aneurysm, peripheral arterial disease and hypertension in men aged 65-74 years from a population screening study (VIVA trial).

BACKGROUND: Abdominal aortic aneurysm (AAA) screening has been introduced into some health systems and could easily be supplemented with broader vascular screening. The aim of this study was to evaluate the screening set-up and investigate combined screening for AAA, peripheral arterial disease (PAD) and possible hypertension (HT), and detection rates. METHODS: This observational study was based on the intervention arm of a screening trial in 25 083 Danish men aged 65-74 years. A combined screening programme for AAA, PAD and HT was offered at local hospitals. Participants with positive test results were offered secondary prophylaxis and/or referred to their general practitioner. The programme set-up included decentralized screening by three mobile teams at 14 venues. Diagnostic criteria were: aortic diameter at least 30 mm for AAA, ankle : brachial pressure index below 0·9 or above 1·4 for PAD, and BP exceeding 160/100 mmHg for HT. RESULTS: Overall, 18 749 men (uptake 74·7 per cent) attended the screening. An AAA was diagnosed in 3·3 (95 per cent c.i. 3·0 to 3·6) per cent, PAD in 10·9 (10·5 to 11·4) per cent and HT in 10·5 (10·0 to 10·9) per cent. Lipid-lowering and/or antiplatelet treatment was initiated in 34·8 per cent of the participants. CONCLUSION: Preventive actions were started in one-third of the attenders. The long-term effect of this on morbidity and mortality is an important part of future analysis. The trial confirms that the prevalence of AAA in Denmark has decreased only slightly in the past decade, from 4·0 to 3·3 per cent, in contrast to other nations.

Statin use and rupture of abdominal aortic aneurysm.

BACKGROUND: Ruptured abdominal aortic aneurysm (rAAA) is associated with high mortality. Research suggests that statins may reduce abdominal aortic aneurysm (AAA) growth and improve rAAA outcomes. However, the clinical impact of statins remains uncertain in relation to both the risk and prognosis of rAAA. METHODS: This nationwide, population-based, combined case-control and follow-up study included all patients (aged at least 50 years) with a first-time hospital admission for rAAA and 1:1 matched AAA controls without rupture in Denmark from 1996 to 2008. Individual-level data on preadmission drug use, co-morbidities, socioeconomic markers, healthcare contacts and death were obtained from Danish nationwide registries. RESULTS: The study included 3584 cases and 3584 matched controls. Current statin use was registered for 418 patients with rAAA (11.7 per cent) and 539 AAA controls (15.0 per cent), corresponding to an age- and sex-matched odds ratio (OR) of 0.70 (95 per cent confidence interval (c.i.) 0.60 to 0.81) for rAAA in current statin users versus never users. The decreased risk of rAAA remained after adjustment for potential confounding factors (adjusted OR 0.73, 0.61 to 0.86). The overall 30-day mortality rate from time of hospital admission among patients with rAAA was 46.1 per cent in current statin users compared with 59.3 per cent in never users (adjusted mortality rate ratio (MRR) 0.80, 95 per cent c.i. 0.68 to 0.95). Patients who had formerly used statins did not have reduced mortality (adjusted MRR 0.98, 0.78 to 1.22). CONCLUSION: Statin use was associated with a reduced risk of rAAA and lower case fatality following rAAA. These results support current guidelines that recommend statin therapy in patients diagnosed with AAA.

Abdominal aortic diameter is increased in males with a family history of abdominal aortic aneurysms: results from the Danish VIVA-trial.

OBJECTIVE: To investigate, at a population level, whether a family history of abdominal aortic aneurysm (AAA) is independently related to increased aortic diameter and prevalence of AAA in men, and to elucidate whether the mean aortic diameter and the prevalence of AAA are different between participants with male and female relatives with AAA. DESIGN: Observational population-based cross-sectional study. MATERIALS: 18,614 male participants screened for AAA in the VIVA-trial 2008-2011 with information on both family history of AAA and maximal aortic diameter. METHODS: Standardized ultrasound scan measurement of maximum antero-posterior aortic diameter. Family history obtained by questionnaire. Multivariate regression analysis was used to test for confounders: age, sex, smoking, comorbidity and medication. RESULTS: From the screened cohort, 569 participants had at least one first degree relative diagnosed with AAA, and 38 had AAA. Participants with a family history of AAA (+FH) had a significantly larger mean maximum aortic diameter (20.50 mm) compared with participants without family history of AAA (-FH) (19.07 mm, p < .0001), and +FH with female relatives with AAA had significantly larger mean maximum aortic diameter (21.8 mm) than +FH with male relatives (19.9 mm, p = .007). Furthermore the prevalence of AAA was significantly higher among +FH (6.7%) compared with -FH (3.0%) with an odds ratio (OR) of 2.2 (95% CI: 1.6 to 3.2, p < .001) and +FH with female relatives with AAA had a more than two and a half times increased prevalence of AAA compared with +FH with male relatives with AAA with an OR of 2.65. CONCLUSIONS: First-degree male relatives of AAA patients have wider aortas and a twofold higher prevalence of AAA compared with the age adjusted background population. The prevalence of AAA was markedly higher in participants related to female, rather than male, patients with AAA.

Mural thrombus and the progression of abdominal aortic aneurysms: a large population-based prospective cohort study.

OBJECTIVE: To investigate whether the relative size of intraluminal thrombus (ILT) in abdominal aortic aneurysms (AAAs) is associated with AAA growth. METHODS: This large observational study was based on a randomised population-based screening trial. Six hundred and fifteen AAAs were diagnosed in men aged 65-74 years. The relative cross-sectional area covered by the mural thrombus was estimated by a semiautomatic method using ultrasound equipment to measure the area of the ellipses, and adapting the inner ellipse (IA) to the luminal border of the thrombus and the outer ellipse to the area inside the media border (OA). The relative thrombus area was then calculated as ((OA-IA)/OU) × 100%. Four hundred and sixteen of the patients with AAA were eligible for analysis. RESULTS: The mean size of the AAA was 40.6 mm, and the mean observation time was 1.78 years. In the group with AAAs measuring 30-34 mm, 42% had ILT, with a mean relative size of 12% of the outer area. In the group with AAAs measuring >64 mm, the presence of ILT increased to 100%, with a mean relative size of 70% of the outer area. Univariate analysis showed relative ILT size, aortic diameter, smoking history, and diastolic blood pressure were significantly positively associated with growth rate, while the presence of diabetes mellitus was significantly negatively associated with growth rate. The relative ILT size remained significantly positively associated with the growth rate after a multivariate linear regression adjusting for potential confounders. CONCLUSION: These findings suggest that ILT may play a part in the progression of AAAs.

Lack of association between inguinal hernia and abdominal aortic aneurysm in a population-based male cohort.

BACKGROUND: Previous studies have reported a higher prevalence of inguinal hernia in patients with abdominal aortic aneurysm (AAA). The aim of this study was to explore the association between inguinal hernia and AAA in a large population-based cohort of men who had screening for AAA. METHODS: A total of 18,331 men aged 65-76 years had ultrasound screening for AAA in the Central Region of Denmark from 2008 to 2010. The Danish National Patient Registry was interrogated, and screened men registered with an inguinal hernia from 1977 to 2011 were identified. The association between inguinal hernia and AAA was assessed by multiple logistic regression analysis. RESULTS: The prevalence of AAA was 3.3 per cent (601 of 18,331). A total of 2936 (16.0 per cent) of the 18,331 patients were registered with a diagnosis of inguinal hernia or hernia repair. Inguinal hernia was not associated with AAA: crude odds ratio (OR) 0.86 (95 per cent confidence interval 0.68 to 1.09) and adjusted OR 0.94 (0.75 to 1.20). CONCLUSION: In contrast to smaller patient-based studies, this large population-based study found no association between inguinal hernia and AAA.

Beta-blocker use and clinical outcomes after primary vascular surgery: a nationwide propensity score-matched study.

OBJECTIVE: To explore the associations between beta-blocker use and clinical outcomes (death, hospitalisation with myocardial infarction (MI) or stroke, major amputation and recurrent vascular surgery) after primary vascular reconstruction. METHODS: Patients who had primary vascular surgical or endovascular reconstruction due to symptomatic peripheral arterial disease, in Denmark between 1996 and 2007 were included. We obtained data on filled prescriptions, clinical outcomes and confounding factors from population-based healthcare registries. Beta-blocker users were matched to non-users by propensity score, and Cox-regression was performed. All medications were included as time-dependent variables. RESULTS: We studied 16,945 matched patients (7828 beta-blocker users and 9117 non-users) with a median follow-up period of 582 days (range, 30-4379 days). The cumulative risks were as follows: all-cause mortality, 17.9%; MI, 5.3%; stroke, 5.6%; major amputation, 9.1%; and recurrent vascular surgery, 23.1%. When comparing beta-blocker users with non-users: adjusted hazard ratio: MI, 1.52 (95% CI, 1.31-1.78); stroke, 1.21 (95% CI, 1.03-1.43); and major amputation, 0.80 (95% CI, 0.70-0.93). CONCLUSION: Beta-blocker use after primary vascular surgery was associated with a lower risk of major amputation but an increased risk of hospitalisation with MI and stroke. No associations were found between beta-blocker use and all-cause mortality or the risk of recurrent vascular surgery. However, our results are not sufficient to alter the indication for beta-blocker use among symptomatic peripheral arterial disease patients.

A multicentre observational study of the outcomes of screening detected sub-aneurysmal aortic dilatation.

OBJECTIVES: Currently most abdominal aortic aneurysm screening programmes discharge patients with aortic diameter of less than 30 mm. However, sub-aneurysmal aortic dilatation (25 mm-29 mm) does not represent a normal aortic diameter. This observational study aimed to determine the outcomes of patients with screening detected sub aneurysmal aortic dilatation. DESIGN AND METHODS: Individual patient data was obtained from 8 screening programmes that had performed long term follow up of patients with sub aneurysmal aortic dilatation. Outcome measures recorded were the progression to true aneurysmal dilatation (aortic diameter 30 mm or greater), progression to size threshold for surgical intervention (55 mm) and aneurysm rupture. RESULTS: Aortic measurements for 1696 men and women (median age 66 years at initial scan) with sub-aneurysmal aortae were obtained, median period of follow up was 4.0 years (range 0.1-19.0 years). Following Kaplan Meier and life table analysis 67.7% of patients with 5 complete years of surveillance reached an aortic diameter of 30 mm or greater however 0.9% had an aortic diameter of 54 mm. A total of 26.2% of patients with 10 complete years of follow up had an AAA of greater that 54 mm. CONCLUSION: Patients with sub-aneurysmal aortic dilatation are likely to progress and develop an AAA, although few will rupture or require surgical intervention.

Measuring the maximum diameter of native abdominal aortic aneurysms: review and critical analysis.

OBJECTIVES: Maximum diameter is a determinant parameter for the clinical management of asymptomatic abdominal aortic aneurysm (AAA). However, its measurement is not standardised. We review the different methods used to measure AAA maximum diameter, with ultrasound (US) or computed tomography (CT). METHODS: A review of maximum diameter measurement methods with US and CT was performed, focussing on screening, surveillance before repair and decision for intervention. Diameter measurement methodology was described according to four parameters: plane of acquisition, axis of measurement, position of callipers and selected diameter. A quality score to evaluate methodology descriptions was defined (plane, axis, callipers placement and selected diameter), ranging from 0 (worst) to 4 (best). RESULTS: Review showed a wide range of definitions and practices. The mean value of the quality score was 2.52 in screening studies, 1.66 in guidelines for screening, 2.81 in follow-up studies and 1.63 in studies describing decision for intervention. CONCLUSION: To improve the efficiency of AAA management (in screening programmes, follow-up and decision for intervention), and enable comparison between future studies, a standardised methodology for AAA maximum diameter measurement is necessary. Until such a consensus is reached, publications should at least clearly report the method of measurement.

Rifampicin-soaked silver polyester versus expanded polytetrafluoro-ethylene grafts for in situ replacement of infected grafts in a porcine randomised controlled trial.

BACKGROUND: To compare the efficacy of in situ replacement with rifampicin-soaked silver-coated polyester (RSSCP) to that of expanded polytetrafluoroethylene (ePTFE) graft replacements in a porcine model for early aortic prosthetic vascular graft infection (PVGI). MATERIAL AND METHODS: Sixty pigs received polyester or silver-coated grafts with an 8 mm diameter implanted end-to-end in the infrarenal aorta, and the grafts were inoculated with approximately 10(6)Staphylococcus aureus. All developed S. aureus PVGI. Two weeks later, the 52 surviving pigs were randomised to undergo in situ graft replacement with ePTFE or RSSCP grafts followed by oral administration of 300 mg rifampicin and 750 mg ciprofloxacin twice a day, postoperatively. After three weeks, all pigs were sacrificed. In situ perigraft swabs and graft material were analysed for S. aureus quantitatively. RESULTS: Only one out of 25 RSSCP grafts were infected with S. aureus, whereas 15 of 27 ePTFE grafts were infected after 3 weeks (OR = 0.022, 95% CI: 0.002, 0.219, P = 0.001). CONCLUSIONS: In situ replacement with RSSCP grafts and oral rifampicin plus ciprofloxacin is more efficiency in eradicating S. aureus PVGI than ePTFE grafts treated with same oral antibiotics in a porcine aortic PVGI model.

The cardiac cycle is a major contributor to variability in size measurements of abdominal aortic aneurysms by ultrasound.

AIM: The objective of the study was to evaluate the impact of the cardiac cycle on ultrasound measurements of abdominal aortic aneurysm (AAA) diameters. METHODS: In total, 603 AAAs detected by screening were investigated with respect to the maximal systolic and diastolic anterior-posterior aortic diameters during the cardiac cycle using recorded ultrasound video sequences. RESULTS: On average, the systolic AAA diameter was 41.60 mm, and the diastolic AAA diameter was 39.63 mm with a paired mean difference at 1.94 mm (p < 0.0001). No association between aneurysmal size and difference in systolic and diastolic size was noted. The mean difference and variability between two observers, one measured during peak-systole and the other measured during end-diastole, was 2.65 and 2.21 mm, respectively, as compared with 0.86 and 1.52 mm, respectively, when both were measured during the peak of systole. The intraobserver variability was 0.94 during systole, 1.18 during diastole and 1.94 mm when systole and diastole measurements were combined. CONCLUSION: The lack of a standardised measurement of the AAA diameter during the cardiac cycle is a potential major contributor to the variability in ultrasonography measurements.

Age- and gender-related differences in the use of secondary medical prevention after primary vascular surgery: a nationwide follow-up study.

OBJECTIVE: This study examined the possible age- and gender-related differences in the use of secondary medical prevention following primary vascular reconstruction in a population-based long-term follow-up study. METHODS: Using information from nationwide Danish registers, we identified all patients undergoing primary vascular reconstruction in-between 1996 and 2006 (n = 20,761). Data were obtained on all filled prescriptions 6 months and 3, 5 and 10 years after primary vascular reconstruction. Comparisons were made across age and gender groups, using men 40-60 years old as a reference. RESULTS: Compared to current guidelines the overall use of secondary medical prevention was moderate to low (e.g., lipid-lowering drugs 49.5%, angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists (ACE/ATII) 43.4%, combination of lipid-lowering drugs and anti-platelet therapy and any anti-hypertensive therapy 44.7%). A decline was observed between 6 months and 3 years after surgery. Patients >80 years old were less likely to be prescribed lipid-lowering drugs and combination therapy (e.g.: adjusted risk ratio (RR) 5 years after surgery for men and women 0.63 (95% confidence interval (CI): 0.39-1.02) and 0.48 (95%CI: 0.31-0.75), respectively, whereas smaller and statistical non-significant gender-related differences were observed. The age- and gender-related differences appeared eliminated or substantially reduced in the latest part of the study period (2001-2007). CONCLUSION: We found moderate to low use of secondary medical prevention in Denmark compared with recommendations from clinical guidelines. However, the use has increased in recent years and age- and gender-related differences have been reduced or even eliminated.