A Swedish primary healthcare prevention programme focusing on promotion of physical activity and a healthy lifestyle reduced cardiovascular events and mortality: 22-year follow-up of 5761 study participants and a reference group.

OBJECTIVE: To evaluate long-term risk of first cardiovascular (CV) events, CV deaths and all-cause deaths in community-dwelling participants of a cardiovascular disease (CVD) prevention programme delivered in a primary care setting. METHODS: Individuals who visited a primary healthcare service in Sollentuna (Sweden) and agreed to participate in the programme between 1988 and 1993 were followed. They had at least one CV risk factor but no prior myocardial infarction and received support to increase physical activity using the programme Physical Activity on Prescription and to adopt health-promoting behaviours including cooking classes, weight reduction, smoking cessation and stress management. Participants (n=5761) were compared with a randomly selected, propensity score-matched reference group from the general population in Stockholm County (n=34 556). All individuals were followed in Swedish registers until December 2011. RESULTS: In the intervention group and the reference group there were 698 (12.1%) and 4647 (13.4%) first CV events, 308 (5.3%) and 2261 (6.5%) CV deaths, and 919 (16.5%) and 6405 (18.5%) all-cause deaths, respectively, during a mean follow-up of 22 years. The HR (95% CI) in the intervention group compared with the reference group was 0.88 (0.81 to 0.95) for first CV events, 0.79 (0.70 to 0.89) for CV deaths and 0.83 (0.78 to 0.89) for all-cause deaths. CONCLUSIONS: Participation in a CVD prevention programme in primary healthcare focusing on promotion of physical activity and healthy lifestyle was associated with lower risk of CV events (12%), CV deaths (21%) and all-cause deaths (17%) after two decades. Promoting physical activity and healthy living in the primary healthcare setting may prevent CVD.

Predicted impact of lipid lowering therapy on cardiovascular and economic outcomes of Swedish atherosclerotic cardiovascular disease guideline.

BACKGROUND: The effects on cardiovascular disease (CVD) by treatment recommendations on prevention of atherosclerotic CVD remain to be evaluated. The objectives were to assess treatment gap for low density lipoprotein cholesterol (LDL-C) according to guidelines, potential impact on CVD outcomes, and possible avoided economic costs, in post myocardial infarction (MI) patients, if target LDL-C levels of ≤1.8 mmol/L would be achieved. METHODS: All patients registered in the Swedish Secondary Prevention after Heart Intensive care Admission register, with one-year post-MI follow-up during 2013 were selected. The REACH risk prediction and a calibrated model for recurrent cardiovascular events and death were used to estimate unadjusted risk prediction based on the REACH equation henceforth called base case, and calibrated CVD outcomes based on gender-specific risk factors. The predicted impact of the LDL-C reduction on the risk of CVD was based on the Cholesterol Treatment Trialists´ Collaboration findings. RESULTS: A sample of n = 5904 patients (74% men) with a mean age of 64 years were included. Around 70% did not reach LDL-C target ≤1.8 mmol/L. Over a 10-year period, 820-2262 events were predicted to occur in those who did not reach target corresponding to 20% - 55% risk of CVD events. To achieve LDL-C target, the mean LDL-C had to be reduced by 0.73 mmol/L (29%). If this LDL-C reduction was achieved, 195-544 life years, 132-343 CVD events, and 7.9-20.9 million Swedish crowns (MSEK) of direct costs, and 19.3-51.0 MSEK of total costs would be avoided. CONCLUSION: Lowering of LDL cholesterol to achieve target levels according to guidelines for post-MI patients may lead to fewer cardiovascular events and avoidance of event costs.

Physicians' gender is associated with risk factor control in patients on antihypertensive and lipid lowering treatment.

The objective was to study gender differences in cardiovascular risk factors, lipid and blood pressure control in patients on combined lipid-lowering and antihypertensive treatment, in relation to gender of their physician. This was a cross-sectional study of 4319 patients (53% men) on lipid-lowering and antihypertensive treatment from two national surveys. Male physicians included 1643 men and 1311 women, and female physicians 605 men and 648 women. All data were collected consecutively from medical records. Women were older, had a higher systolic blood pressure (SBP), pulse pressure (PP), total cholesterol (TC), low-density lipoprotein-cholesterol (LDL-C), SBP>or=140 mmHg, and more often isolated systolic hypertension (ISH) compared with men. Men compared with women had more often diabetes, higher cardiovascular risk (SCORE) and achieved treatment goals more often for blood pressure in non-diabetics and TC in both non-diabetics and diabetics. Both men and women in well controlled and intermediate controlled groups were more often treated by physicians of their own gender. The female diabetes patients treated by female primary healthcare physicians more often achieved treatment goals for blood pressure [SBP/diastolic blood pressure (DBP)<130/80 mmHg]. Female physicians' male patients with diabetes more often belonged to the well controlled group. Physicians' gender may influence the control of risk factors for cardiovascular disease in both men and women on combined antihypertensive and lipid-lowering therapy.

Association of physician's sex with risk factor control in treated hypertensive patients from Swedish primary healthcare.

OBJECTIVE: To study the association of physician's sex with blood pressure, lipid control, and cardiovascular risk factors in treated hypertensive men and women, stratified for the sex of their physician. METHODS: In a cross-sectional survey of hypertensive patients, 264 primary care physicians (PCPs), 187 men and 77 women from across Sweden, recruited 6537 treated hypertensive patients (48% men) during 2002-2005, consecutively collected from medical records and registered on a web-based form connected to a central database. Patients were included consecutively in the same order as they visited the healthcare centre. RESULTS: Hypertensive women more often reached target systolic/diastolic blood pressure levels (<140/90 mmHg) when treated by female PCPs than when they were treated by male PCPs (32 vs. 24%, P < 0.001). This difference remained when comparing female and male physicians' nondiabetic female patients. Both male and female patients had better control of total cholesterol and low-density lipoprotein cholesterol levels when treated by female PCPs than when treated by male PCPs (total cholesterol <5 mmol/l: women 30 vs. 24%, P < 0.001; men 42 vs. 34%, P < 0.001; low-density lipoprotein cholesterol <3 mmol/l: women 39 vs. 33%, P < 0.01; men 41 vs. 35%, P < 0.05). Female PCPs had a higher proportion of treated hypertensive patients with diabetes than did male PCPs but male PCPs had a higher prevalence of treated hypertensive men with microalbuminuria compared with female PCPs. CONCLUSION: Female physicians appeared more often to reach the treatment goal for blood pressure in female patients and cholesterol levels in all patients than did male physicians.

Time Trends in Incidence and Mortality of Acute Myocardial Infarction, and All-Cause Mortality following a Cardiovascular Prevention Program in Sweden.

BACKGROUND: In 1988, a cardiovascular prevention program which combined an individual and a population-based strategy was launched within primary health-care in Sollentuna, a municipality in Stockholm County. The aim of this study was to investigate time trends in the incidence of and mortality from acute myocardial infarction and all-cause mortality in Sollentuna compared with the rest of Stockholm County during a period of two decades following the implementation of a cardiovascular prevention program. MATERIALS AND METHODS: The average population in Sollentuna was 56,589 (49% men) and in Stockholm County (Sollentuna included) 1,795,504 (49% men) during the study period of 1987-2010. Cases of hospitalized acute myocardial infarction and death were obtained for the population of Sollentuna and the rest of Stockholm County using national registries of hospital discharges and deaths. Acute myocardial infarction incidence and mortality were estimated using the average population of Sollentuna and Stockholm in 1987-2010. RESULTS: During the observation period, the incidence of acute myocardial infarction decreased more in Sollentuna compared with the rest of Stockholm County in women (-22% vs. -7%; for difference in slope <0.05). There was a trend towards a greater decline in Sollentuna compared to the rest of Stockholm County in the incidence of acute myocardial infarction (in men), acute myocardial mortality, and all-cause mortality but the differences were not significant. CONCLUSION: During a period of steep decline in acute myocardial infarction incidence and mortality in Stockholm County the municipality of Sollentuna showed a stronger trend in women possibly compatible with favorable influence of a cardiovascular prevention program. TRIAL REGISTRATION: ClinicalTrials.gov NCT02212145.

Impact of symptomatic hypoglycemia on medication adherence, patient satisfaction with treatment, and glycemic control in patients with type 2 diabetes.

BACKGROUND: The purpose of this study was to evaluate the impact of symptomatic hypoglycemia on medication adherence, satisfaction with treatment, and glycemic control in patients with type 2 diabetes based on the treatment goals stated in the Swedish national guidelines. METHODS: This cross-sectional, multicenter study was carried out between January and August 2009 in 430 consecutive primary health care patients on stable doses of metformin and sulfonylureas for at least 6 months. The patients completed questionnaires covering their experiences of low blood glucose and adherence, as well as barriers to and satisfaction with drug treatment (using the Treatment Satisfaction Questionnaire for Medication). Physicians collected the data from medical records. RESULTS: Patients who experienced moderate or worse symptoms of hypoglycemia reported poorer adherence to medication (46% versus 67%; P<0.01) and were more likely to perceive barriers such as "bothered by medication side effects" (36% versus 14%; P<0.001) compared with patients with no or mild symptoms. Patients with moderate or worse symptoms of hypoglycemia were less satisfied with their treatment than those with no or mild symptoms as determined by the Treatment Satisfaction Questionnaire for Medication-Global satisfaction (67.0 versus 71.2; P<0.05). Overall, achievement of target glycated hemoglobin (HbA1c) based on the treatment goals stated in the Swedish national guidelines was 40%. Despite poorer adherence, patients who experienced moderate or worse symptoms of hypoglycemia had lower mean HbA1c values than patients with no or mild symptoms (7.0% versus 7.3% [Diabetes Control and Complications Trial standard]; P<0.05). CONCLUSION: Symptomatic hypoglycemia in patients with type 2 diabetes on metformin and sulfonylureas was associated with nonadherence and decreased treatment satisfaction despite lower mean HbA1c values. A broader understanding of patient preferences and self-reported outcomes could improve the management of patients with type 2 diabetes.

Self-reported experience of hypoglycemia among adults with type 2 diabetes mellitus (Exhype).

AIMS: To evaluate the experience of hypoglycemia in patients treated with metformin in combination with sulphonylureas (SUs) and the impact on patients' quality of life (QoL) and worry about hypoglycemia. METHODS: This was a national, cross-sectional, multicenter study. Patients with type 2 diabetes treated with metformin and SU dual therapy were recruited by 54 investigators between January 2009 and August 2009. The patients were asked to complete a QoL instrument, the EuroQol-5 Dimensions questionnaire (EQ-5D), and the Hypoglycemia Fear Survey (HFS-II). Investigators completed a web-based case report form on laboratory values, medical history and anti-diabetic treatment. RESULTS: A total of 430 patients (60% male) were included in the study. Mean age was 69 years. Approximately one fifth of the patients experienced moderate or worse symptoms of hypoglycemia. Patients who experienced moderate or worse hypoglycemia had lower QoL as measured by the weighted EQ-5D summary score (0.81 vs. 0.88; p<0.001) than patients who experienced mild or no hypoglycemia. CONCLUSIONS: Experience of hypoglycemia was found to be associated with lower QoL in patients with type 2 diabetes on dual treatment with metformin and sulphonylurea. This should be taken into consideration when selecting treatment for these patients in clinical practice.

Factors associated with uncontrolled hypertension and cardiovascular risk in hypertensive 60-year-old men and women--a population-based study.

The objective of this study was to describe cardiovascular risk profiles of 60-year-olds with uncontrolled diagnosed hypertension (>or=140/90 mm Hg) in comparison with individuals with controlled diagnosed hypertension. To study how medical, lifestyle and socioeconomic factors are associated with uncontrolled diagnosed hypertension in men and women separately, a population-based, cross-sectional study of 4228 60-year-olds in Sweden, of whom 503 men and 445 women had previously diagnosed hypertension, was conducted. Physical examination including measuring blood pressure was carried out, and a medical/lifestyle/socioeconomic questionnaire was completed. Only 22% of the men and 33% of the women with diagnosed hypertension had a blood pressure below 140/90 mm Hg. Both men and women had multiple cardiovascular risk factors in addition to hypertension. Antihypertensive monotherapy was more common in men and women with controlled hypertension. None of the participants without pharmacological treatment had a controlled blood pressure. Four factors were independently associated with uncontrolled hypertension in men: waist circumference above 97 cm (odds ratio (OR)=1.85, confidence interval (CI)=1.17-2.92), coronary heart disease (CHD) (OR=0.28, CI=0.17-0.46), no health care for financial reasons (OR=2.71, CI=1.09-6.78) and daily intake of fruit (OR=0.59, CI=0.37-0.93). In women, three factors remained independently associated: waist circumference above 78 cm (OR=1.93, CI=1.09-3.43), CHD (OR=0.36, CI=0.18-0.72) and living in an apartment (OR=0.55, CI=0.35-0.85). More efforts are warranted to reduce blood pressure and to modulate associated risk factors to be able to reduce the high morbidity and mortality observed in individuals with hypertension.

Sex differences in risk factor control of treated hypertensives: a national primary healthcare-based study in Sweden.

BACKGROUND: To evaluate potential sex differences, this study aimed to investigate blood pressure and lipid control and other risk factors for cardiovascular disease in treated hypertensive (tHT) patients from primary healthcare. DESIGN AND METHODS: This cross-sectional survey of tHT patients was carried out between 2002 and 2005 by 264 primary care physicians from Sweden who consecutively recruited 6537 tHT patients (48% men and 52% women) from medical records. RESULTS: tHT men more often reached the treatment goal for systolic/diastolic blood pressure, less than 140/90 mmHg, than tHT women (30 vs. 26%, P<0.01). Men had lower systolic blood pressure than women, however, women had lower diastolic blood pressure and higher pulse pressure. More tHT women had total cholesterol>or=5.0 mmol/l than corresponding men (75 vs. 64% P<0.001). Men more often had diabetes (25 vs. 20% P<0.001), left ventricular hypertrophy (20 vs. 16% P<0.001), and microalbuminuria (24 vs. 16% P<0.001). Women were more often treated with diuretics (64 vs. 48%) and beta-receptor blockers (54 vs. 51%), and men more often treated with angiotensin-converting enzyme inhibitors (27 vs. 18%), calcium channel blockers (34 vs. 26%), and lipid-lowering drugs (34 vs. 29%). CONCLUSION: A need still exists for more intensified treatment of elevated blood pressure and hypercholesterolemia, especially in women. In hypertensives of both sexes, smoking and other risk factors also need to be addressed to reduce the risk of cardiovascular disease.

Risk factor control in treated hypertensives from Estonia and Sweden. Why the difference?

BACKGROUND: It is of importance to study the risk factor control in treated hypertensives (tHT), both longitudinally within one country and between neighbouring countries, as hypertensive patients still run an increased cardiovascular risk in spite of treatment. METHODS: In sample of 1135 tHT from Estonia and a similar number of age- and sex-matched Swedish tHT, the control of blood pressure and other cardiovascular risk factors were assessed as part of national surveys in primary health care. Data were retrieved form consecutive patients visiting primary health care centres all over each country. RESULTS: The mean age of male patients (n = 421) was 50 years and for female patients (n = 714) it was 52 years. tHT from Sweden were more likely to be in better control of blood pressure and risk factor levels than corresponding Estonian patients, matched for age and gender. However, there was a significantly (p = 0.0003) higher rate of smoking in Swedish female patients (22.4%) than in corresponding Estonian patients (16.0%). More Swedish women than men were prescribed thiazide diuretics, but fewer were prescribed angiotensin-converting enzyme (ACE) inhibitors. No similar Estonian data were available. CONCLUSION: Most cardiovascular risk factors were better controlled in the Swedish hypertensives, except for a higher smoking prevalence in Swedish female patients. This could be related not only to differences in clinical practice, but also influenced by social and lifestyle factors.

Hypertensive smokers have a worse cardiovascular risk profile than non-smokers in spite of treatment--a national study in Sweden.

Smoking is a well-established risk factor for cardiovascular disease. Studies have indicated that smoking may outweigh the benefit of blood pressure (BP) control. Our aim was to compare cardiovascular risk factors in smokers vs non-smokers from a national sample of treated hypertensives. Data were collected on smoking habits, BP control, total and low-density lipoprotein (LDL) cholesterol, diabetes, left ventricular hypertrophy (LVH), and microalbuminuria (MA), from records of 4424 consecutive patients by 189 physicians. All technical methods were local. Treated hypertensives who smoked had microalbuminuria significantly more often than non-smokers, 26.2% vs 20.5% (p<0.05), and a higher proportion of smokers were suboptimally controlled (DBP > or = 90 mmHg), 32.7% vs 25.0% (p<0.01). Smoking males had a higher prevalence of LVH (25.7% vs 20.1; p<0.05), microalbuminuria (29.7% vs 24.7%; p<0.01), and a higher proportion of subjects with uncontrolled systolic BP (> or = 140 mmHg) (72.8% vs 68.9%; p<0.01). Both DBP and total cholesterol were higher in smoking vs non-smoking females. An increased prevalence of LVH and microalbuminuria was independently associated with smoking. In summary, smokers with treated hypertension show a higher proportion of LVH (men), microalbuminuria and worse diastolic BP control than non-smokers. This may hypothetically reflect either less compliance with drug treatment in smokers or that smoking impairs the pharmacological effects of antihypertensive drugs.

Gender differences in risk factor control and treatment profile in diabetes: a study in 229 swedish primary health care centres.

OBJECTIVE: To measure the risk factors and treatment profile of diabetes patients treated in primary health care (PHC) in order to evaluate potential gender differences. DESIGN: Cross-sectional survey of consecutive diabetes patients. SETTING: 229 PHC centres in Sweden. SUBJECTS: 5082 men and 4293 women with diabetes were investigated (1998-2001). MAIN OUTCOME MEASURES: Glycaemic control (HbA1c), blood pressure, lipid levels, prevalence of left ventricular hypertrophy and microalbuminuria. Proportions of patients with previous ischaemic heart disease (IHD) and specific drug treatment. RESULTS: Male patients generally had better blood pressure ( < 140 and/or 85 mmHg) and glycaemic (HbA1c < 6.5%) control than corresponding female patients (44% and 59%, versus 40% and 54% in the 60-75 year age group; p < 0.01). Females showed higher levels of total (p < 0.01) and HDL cholesterol (p < 0.05) than males in all age groups. No gender difference was detected for LDL cholesterol levels in the younger or elderly patients, but in the age group 60-75 years female patients had significantly higher mean LDL cholesterol level than male patients (3.3 vs 3.2 mmol/L; p < 0.05). Previously known manifestations of IHD were more common (p < 0.01) in male patients. CONCLUSION: Elderly male patients with diabetes had a more favourable risk factor control than corresponding female patients.