Variation in secondary prevention of coronary heart disease: the INTERASPIRE study.

BACKGROUND AND AIMS: INTERASPIRE is an international study of coronary heart disease (CHD) patients, designed to measure if guideline standards for secondary prevention and cardiac rehabilitation are being achieved in a timely manner. METHODS: Between 2020 and 2023, adults hospitalized in the preceding 6-24 months with incident or recurrent CHD were sampled in 14 countries from all 6 World Health Organization regions and invited for a standardized interview and examination. Direct age and sex standardization was used for country-level prevalence estimation. RESULTS: Overall, 4548 (21.1% female) CHD patients were interviewed a median of 1.05 (interquartile range .76-1.45) years after index hospitalization. Among all participants, 24.6% were obese (40.7% centrally). Only 38.6% achieved a blood pressure (BP) < 130/80 mmHg and 16.6% a LDL cholesterol (LDL-C) of <1.4 mmol/L. Of those smoking at hospitalization, 48% persisted at interview. Of those with known diabetes, 55.2% achieved glycated haemoglobin (HbA1c) of <7.0%. A further 9.8% had undetected diabetes and 26.9% impaired glucose tolerance. Females were less likely to achieve the targets: BP (females 36.8%, males 38.9%), LDL-C (females 12.0%, males 17.9%), and HbA1c in diabetes (females 47.7%, males 57.5%). Overall, just 9.0% (inter-country range 3.8%-20.0%) reported attending cardiac rehabilitation and 1.0% (inter-country range .0%-2.4%) achieved the study definition of optimal guideline adherence. CONCLUSIONS: INTERASPIRE demonstrates inadequate and heterogeneous international implementation of guideline standards for secondary prevention in the first year after CHD hospitalization, with geographic and sex disparity. Investment aimed at reducing between-country and between-individual variability in secondary prevention will promote equity in global efforts to reduce the burden of CHD.

Gender differences in screening for glucose perturbations, cardiovascular risk factor management and prognosis in patients with dysglycaemia and coronary artery disease: results from the ESC-EORP EUROASPIRE surveys.

BACKGROUND: Gender disparities in the management of dysglycaemia, defined as either impaired glucose tolerance (IGT) or type 2 diabetes (T2DM), in coronary artery disease (CAD) patients are a medical challenge. Recent data from two nationwide cohorts of patients suggested no gender difference as regards the risk for diabetes-related CV complications but indicated the presence of a gender disparity in risk factor management. The aim of this study was to investigate gender differences in screening for dysglycaemia, cardiovascular risk factor management and prognosis in dysglycemic CAD patients. METHODS: The study population (n = 16,259; 4077 women) included 7998 patients from the ESC-EORP EUROASPIRE IV (EAIV: 2012-2013, 79 centres in 24 countries) and 8261 patients from the ESC-EORP EUROASPIRE V (EAV: 2016-2017, 131 centres in 27 countries) cross-sectional surveys. In each centre, patients were investigated with standardised methods by centrally trained staff and those without known diabetes were offered an oral glucose tolerance test (OGTT). The first of CV death or hospitalisation for non-fatal myocardial infarction, stroke, heart failure or revascularization served as endpoint. Median follow-up time was 1.7 years. The association between gender and time to the occurrence of the endpoint was evaluated using Cox survival modelling, adjusting for age. RESULTS: Known diabetes was more common among women (32.9%) than men (28.4%, p < 0.0001). OGTT (n = 8655) disclosed IGT in 17.2% of women vs. 15.1% of men (p = 0.004) and diabetes in 13.4% of women vs. 14.6% of men (p = 0.078). In both known diabetes and newly detected dysglycaemia groups, women were older, with higher proportions of hypertension, dyslipidaemia and obesity. HbA1c was higher in women with known diabetes. Recommended targets of physical activity, blood pressure and cholesterol were achieved by significantly lower proportions of women than men. Women with known diabetes had higher risk for the endpoint than men (age-adjusted HR 1.22; 95% CI 1.04-1.43). CONCLUSIONS: Guideline-recommended risk factor control is poorer in dysglycemic women than men. This may contribute to the worse prognosis in CAD women with known diabetes.

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.

Cardiac Rehabilitation: Under-Utilized Globally.

PURPOSE OF REVIEW: Cardiac rehabilitation (CR) is grossly under-utilized. This review summarizes current knowledge about degree of CR utilization, reasons for under-utilization, and strategies to increase use. RECENT FINDINGS: ICCPR's global CR audit quantified for the first time the number of additional CR spots needed per year to treat indicated patients, so there are programs they may use. The first randomized trial of automatic/systematic CR referral has shown it results in significantly greater patient completion. Moreover, the recent update of the Cochrane review on interventions to increase use has provided unequivocal evidence on the significant impact of clinician CR encouragement at the bedside; a course is now available to train clinicians. The USA is leading the way in implementing automatic referral with inpatient-clinician CR discussions. Suggestions to triage patients based on risk to less resource-intensive, unsupervised program models could simultaneously expand capacity and support patient adherence.

INTERASPIRE: an International Survey of Coronary Patients; Their Cardiometabolic, Renal and Biomarker Status; and the Quality of Preventive Care Delivered in All WHO Regions : In Partnership with the World Heart Federation, European Society of Cardiology, Asia Pacific Society of Cardiology, InterAmerican Society of Cardiology, and PanAfrican Society of Cardiology.

PURPOSE OF REVIEW: To describe the INTERASPIRE scientific protocol-an international survey of secondary prevention of coronary heart disease (CHD). RECENT FINDINGS: This international survey is being conducted through National Societies of Cardiology in selected countries from each of the six WHO regions and has the following overall aims: (i) describe prevalence of cardiometabolic and renal risk factors together with biomarkers in CHD patients; (ii) describe current risk factor management through lifestyle changes and cardioprotective drug therapies; (iii) provide an objective assessment of clinical implementation of preventive care by comparison with the lifestyle and risk factor targets defined in international and national guidelines; (iv) investigate the reasons for variation in preventive cardiology practice between regions and countries; and (v) promote the principles of best preventive cardiology practice. This international survey will provide a unique picture of CHD patients; their cardiometabolic, renal and biomarker status; lifestyle and therapeutic management; and the quality of preventive care provided in all WHO regions.

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.

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.

Undetected dysglycaemia common in primary care patients treated for hypertension and/or dyslipidaemia: on the need for a screening strategy in clinical practice. A report from EUROASPIRE IV a registry from the EuroObservational Research Programme of the European Society of Cardiology.

BACKGROUND: Dysglycaemia defined as type 2 diabetes (T2DM) and impaired glucose tolerance (IGT), increases the risk of cardiovascular disease (CVD). The negative impact is more apparent in the presence of hypertension and/or dyslipidaemia. Thus, it seems reasonable to screen for dysglycaemia in patients treated for hypertension and/or dyslipidaemia. A simple screening algorithm would enhance the adoption of such strategy in clinical practice. OBJECTIVES: To test the hypotheses (1) that dysglycaemia is common in patients with hypertension and/or dyslipidaemia and (2) that initial screening with the Finnish Diabetes Risk Score (FINDRISC) will decrease the need for laboratory based tests. METHODS: 2395 patients (age 18-80 years) without (i) a history of CVD or TDM2, (ii) prescribed blood pressure and/or lipid lowering drugs answered the FINDRISC questionnaire and had an oral glucose tolerance test (OGTT) and HbA1c measured. RESULTS: According to the OGTT 934 (39%) had previously undetected dysglycaemia (T2DM 19%, IGT 20%). Of patients, who according to FINDRISC had a low, moderate or slightly elevated risk 20, 34 and 41% and of those in the high and very high-risk category 49 and 71% had IGT or T2DM respectively. The OGTT identified 92% of patients with T2DM, FPG + HbA1c 90%, FPG 80%, 2hPG 29% and HbA1c 22%. CONCLUSIONS: (1) The prevalence of dysglycaemia was high in patients treated for hypertension and/or dyslipidaemia. (2) Due to the high proportion of dysglycaemia in patients with low to moderate FINDRISC risk scores its initial use did not decrease the need for subsequent glucose tests. (3) FPG was the best test for detecting T2DM. Its isolated use is limited by the inability to disclose IGT. A pragmatic strategy, decreasing the demand for an OGTT, would be to screen all patients with FPG followed by OGTT in patients with IFG.

Secondary Prevention in Younger vs. Older Coronary Heart Disease Patients-Insights from the German Subset of the EUROASPIRE IV Survey.

PURPOSE: Evidence is limited on implementation of secondary prevention guidelines for coronary heart disease (CHD) in clinical practice and variations between younger and elder patients. We investigated the control of cardiovascular risk factors in German patients with CHD enrolled in the European-wide EUROASPIRE IV survey, stratified by younger (18-69 years) and older (70-79 years) age groups. METHOD: Eligible subjects were identified via the hospitals' patient information system and invited to attend a study visit 6 months to 3 years after hospitalization for CHD (myocardial infarction, ischemia, angioplasty/stent, coronary bypass grafting). Information on lifestyle and medication was collected by interview. RESULTS: Five hundred thirty-six patients were recruited in 2012-2013 (median age 69 years [IQR 62-74 years], 18% female, 44% ≥ 70 years of age, median time between index hospitalization and study visit 1.8 [1.1-2.5] years). Proportion of CHD patients receiving recommended drug therapy was 89% for platelet inhibitors (younger vs. older patients 93 vs. 84%, p < 0.01), 83% for statins (83 vs. 85%, p = 0.9), and 83% for beta-blockers (87 vs. 79%, p = 0.02). Uncontrolled blood pressure was observed in 45% (40 vs. 50%, p = 0.02), LDL cholesterol levels > 2.5 mmol/l in 53% (56 vs. 49%, p = 0.1), and HbA1c levels > 7% in diabetic patients in 39% (45 vs. 32%, p = 0.1). Eighty-five percent were overweight (86 vs. 85%, p = 0.8), 37% were obese (41 vs. 31%, p = 0.01), and 10% reported currently smoking (17 vs. 3%, p < 0.01). CONCLUSION: Although most CHD patients received the drug classes recommended by guidelines, treatment goals were frequently not achieved. Elderly subjects had a less favorable pattern, which may reflect multi-morbidity and weaker identification with treatment targets. National CHD prevention strategies should focus not only on enhancing lifestyle modifications and reaching treatment targets, but also on highlighting the different needs in older individuals.

Heart failure in patients with coronary heart disease: Prevalence, characteristics and guideline implementation - Results from the German EuroAspire IV cohort.

BACKGROUND: Adherence to pharmacotherapeutic treatment guidelines in patients with heart failure (HF) is of major prognostic importance, but thorough implementation of guidelines in routine care remains insufficient. Our aim was to investigate prevalence and characteristics of HF in patients with coronary heart disease (CHD), and to assess the adherence to current HF guidelines in patients with HF stage C, thus identifying potential targets for the optimization of guideline implementation. METHODS: Patients from the German sample of the European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EuroAspire) IV survey with a hospitalization for CHD within the previous six to 36 months providing valid data on echocardiography as well as on signs and symptoms of HF were categorized into stages of HF: A, prevalence of risk factors for developing HF; B, asymptomatic but with structural heart disease; C, symptomatic HF. A Guideline Adherence Indicator (GAI-3) was calculated for patients with reduced (≤40%) left ventricular ejection fraction (HFrEF) as number of drugs taken per number of drugs indicated; beta-blockers, angiotensin converting enzyme inhibitors/angiotensin receptor blockers, and mineralocorticoid receptor antagonists (MRA) were considered. RESULTS: 509/536 patients entered analysis. HF stage A was prevalent in n = 20 (3.9%), stage B in n = 264 (51.9%), and stage C in n = 225 (44.2%) patients; 94/225 patients were diagnosed with HFrEF (42%). Stage C patients were older, had a longer duration of CHD, and a higher prevalence of arterial hypertension. Awareness of pre-diagnosed HF was low (19%). Overall GAI-3 of HFrEF patients was 96.4% with a trend towards lower GAI-3 in patients with lower LVEF due to less thorough MRA prescription. CONCLUSIONS: In our sample of CHD patients, prevalence of HF stage C was high and a sizable subgroup suffered from HFrEF. Overall, pharmacotherapy was fairly well implemented in HFrEF patients, although somewhat worse in patients with more reduced ejection fraction. Two major targets were identified possibly suited to further improve the implementation of HF guidelines: 1) increase patients´ awareness of diagnosis and importance of HF; and 2) disseminate knowledge about the importance of appropriately implementing the use of mineralocorticoid receptor antagonists. TRIAL REGISTRATION: This is a cross-sectional analysis of a non-interventional study. Therefore, it was not registered as an interventional trial.

Patient's and physician's awareness of kidney disease in coronary heart disease patients - a cross-sectional analysis of the German subset of the EUROASPIRE IV survey.

BACKGROUND: Chronic kidney disease (CKD) is a common comorbid condition in coronary heart disease (CHD). CKD predisposes the patient to acute kidney injury (AKI) during hospitalization. Data on awareness of kidney dysfunction among CHD patients and their treating physicians are lacking. In the current cross-sectional analysis of the German EUROASPIRE IV sample we aimed to investigate the physician's awareness of kidney disease of patients hospitalized for CHD and also the patient's awareness of CKD in a study visit following hospital discharge. METHODS: All serum creatinine (SCr) values measured during the hospital stay were used to describe impaired kidney function (eGFRCKD-EPI < 60 ml/min/1.73m2) at admission, discharge and episodes of AKI (KDIGO definition). Information extracted from hospital discharge letters and correct ICD coding for kidney disease was studied as a surrogate of physician's awareness of kidney disease. All patients were interrogated 0.5 to 3 years after hospital discharge, whether they had ever been told about kidney disease by a physician. RESULTS: Of the 536 patients, 32% had evidence for acute or chronic kidney disease during the index hospital stay. Either condition was mentioned in the discharge letter in 22%, and 72% were correctly coded according to ICD-10. At the study visit in the outpatient setting 35% had impaired kidney function. Of 158 patients with kidney disease, 54 (34%) were aware of CKD. Determinants of patient's awareness were severity of CKD (OReGFR 0.94; 95%CI 0.92-0.96), obesity (OR 1.97; 1.07-3.64), history of heart failure (OR 1.99; 1.00-3.97), and mentioning of kidney disease in the index event's hospital discharge letter (OR 5.51; 2.35-12.9). CONCLUSIONS: Although CKD is frequent in CHD, only one third of patients is aware of this condition. Patient's awareness was associated with kidney disease being mentioned in the hospital discharge letter. Future studies should examine how raising physician's awareness for kidney dysfunction may improve patient's awareness of CKD.

Screening for dysglycaemia in patients with coronary artery disease as reflected by fasting glucose, oral glucose tolerance test, and HbA1c: a report from EUROASPIRE IV--a survey from the European Society of Cardiology.

AIMS: Three methods are used to identify dysglycaemia: fasting plasma glucose (FPG), 2-h post-load plasma glucose (2hPG) from the oral glucose tolerance test (OGTT), and glycated haemoglobin A1c (HbA1c). The aim was to describe the yield and concordance of FPG, HbA1c, and 2hPG alone, or in combination, to identify dysglycaemia in patients with coronary artery disease. METHODS AND RESULTS: In EUROASPIRE IV, a cross-sectional survey of patients aged 18-80 years with coronary artery disease in 24 European countries, 4004 patients with no reported history of diabetes had FPG, 2hPG, and HbA1c measured. All participants were divided into different glycaemic categories according to the ADA and WHO criteria for dysglycaemia. Using all screening tests together, 1158 (29%) had undetected diabetes. Out of them, the proportion identified by FPG was 75%, by 2hPG 40%, by HbA1c 17%, by FPG + HbA1c 81%, and by OGTT (=FPG + 2hPG) 96%. Only 7% were detected by all three methods FPG, 2hPG, and HbA1c. The ADA criteria (FPG + HbA1c) identified 90% of the population as having dysglycaemia compared with 73% with the WHO criteria (OGTT = FPG + 2hPG). Screening according to the ADA criteria for FPG + HbA1c identified 2643 (66%) as having a 'high risk for diabetes', while the WHO criteria for FPG + 2hPG identified 1829 patients (46%). CONCLUSION: In patients with established coronary artery disease, the OGTT identifies the largest number of patients with previously undiagnosed diabetes and should be the preferred test when assessing the glycaemic state of such patients.

Patients with coronary artery disease and diabetes need improved management: a report from the EUROASPIRE IV survey: a registry from the EuroObservational Research Programme of the European Society of Cardiology.

BACKGROUND: In order to influence every day clinical practice professional organisations issue management guidelines. Cross-sectional surveys are used to evaluate the implementation of such guidelines. The present survey investigated screening for glucose perturbations in people with coronary artery disease and compared patients with known and newly detected type 2 diabetes with those without diabetes in terms of their life-style and pharmacological risk factor management in relation to contemporary European guidelines. METHODS: A total of 6187 patients (18-80 years) with coronary artery disease and known glycaemic status based on a self reported history of diabetes (previously known diabetes) or the results of an oral glucose tolerance test and HbA1c (no diabetes or newly diagnosed diabetes) were investigated in EUROASPIRE IV including patients in 24 European countries 2012-2013. The patients were interviewed and investigated in order to enable a comparison between their actual risk factor control with that recommended in current European management guidelines and the outcome in previously conducted surveys. RESULTS: A total of 2846 (46%) patients had no diabetes, 1158 (19%) newly diagnosed diabetes and 2183 (35%) previously known diabetes. The combined use of all four cardioprotective drugs in these groups was 53, 55 and 60%, respectively. A blood pressure target of <140/90 mmHg was achieved in 68, 61, 54% and a LDL-cholesterol target of <1.8 mmol/L in 16, 18 and 28%. Patients with newly diagnosed and previously known diabetes reached an HbA1c <7.0% (53 mmol/mol) in 95 and 53% and 11% of those with previously known diabetes had an HbA1c >9.0% (>75 mmol/mol). Of the patients with diabetes 69% reported on low physical activity. The proportion of patients participating in cardiac rehabilitation programmes was low (≈40 %) and only 27% of those with diabetes had attended diabetes schools. Compared with data from previous surveys the use of cardioprotective drugs had increased and more patients were achieving the risk factor treatment targets. CONCLUSIONS: Despite advances in patient management there is further potential to improve both the detection and management of patients with diabetes and coronary artery disease.

Comparison of treatment outcomes in patients with and without diabetes mellitus attending a multidisciplinary cardiovascular prevention programme (a retrospective analysis of the EUROACTION trial).

BACKGROUND: The objective was to compare the improvements in lifestyle and risk factor profiles in patients with and without diabetes mellitus (DM) in the intervention arm of EUROACTION study. METHODS: This was a retrospective analysis of the intervention arm of EUROACTION trial. Primary outcome was proportions meeting the European targets for not smoking, diet, physical activity (PA), body mass index (BMI), waist circumference (WC), blood pressure (BP), total and low-density lipoprotein (LDL) cholesterol and cardio-protective drug use at one year. RESULTS: 179 and 777 coronary patients with and without DM, and 340 and 917 high-risk individuals (HRI) with and without DM, respectively were identified. The proportions of coronary patients achieving the lifestyle targets improved from the initial assessment (IA) except non-smoking, which reduced. At one year, significantly fewer patients with DM attained the targets for BMI (13.2% vs 31.3%, p = 0.002) and BP <140/90 mmHg (53.5% vs 74.0%, p < 0.001) compared to patients without DM despite a higher proportion of patients with DM prescribed angiotensin converting enzyme inhibitors/angiotensin receptor blockers (79.1% vs 65.3%, p = 0.021). Among the HRIs, fewer patients with DM achieved targets for oily fish intake (9.3% vs 11.9%, p = 0.043), physical activity (65.8% vs 75.8%, p = 0.011), and BMI (9.9% vs 28.1%, p = 0.022) at one year. While more patients with DM achieved the targets for total cholesterol (48.2% vs 22.9%, p < 0.001) and LDL (57.9% vs 30.7%, p < 0.001). CONCLUSIONS: Multidisciplinary intervention had a beneficial effect on several cardiovascular risk factors in both patients with and without DM. Poorer achievement of mostly lifestyle (and BP in coronary patients) targets among those with DM emphasises the need for more intensive lifestyle modification and BP management for the prevention of cardiovascular disease.

Effectiveness of a preventive cardiology programme for high CVD risk persistent smokers: the EUROACTION PLUS varenicline trial.

AIM: The EUROACTION PLUS trial measured the effectiveness of a nurse-led preventive cardiology programme (EUROACTION) offering intensive smoking cessation PLUS optional varenicline for persistent high CVD risk smokers to reduce overall cardiovascular risk compared with usual care (UC) in general practice (GP). METHODS AND RESULTS: A parallel group randomized controlled trial in 20 GP in Italy, Netherlands, Spain, and UK. Six hundred and ninety-six current smokers, (137 vascular disease and 559 high total CVD risk), were randomized 350 to EUROACTION PLUS (EA+) and 346 to UC. Specially, trained nurses offered the EUROACTION preventive cardiology programme addressing smoking cessation, diet, physical activity, and risk factor management to reduce overall cardiovascular risk. The primary endpoint was 7 day point prevalence of self-reported abstinence (validated breath carbon monoxide <10 p.p.m.) at 16 weeks. Secondary outcomes included dietary habits, physical activity, weight, blood pressure (BP), lipid, and glucose management. One hundred and seventy-seven (51%) EA+ patients (91% opted to use varenicline) were abstinent vs. 63 (19%) in UC; OR 4.52 (95% CI: 3.20-6.39). The Mediterranean diet score of ≥9 in 149 (52%) EA+ patients vs. 97 (37%) in UC; OR 1.84 (95% CI: 1.31-2.59). Physical activity target achieved in 46 (16%) EA+ patients vs. 19 (7%) in UC; OR 2.48 (95% CI: 1.41-4.36). Target BP (<140/90 mm Hg) achieved in 150 (52%) EA+ patients vs. 112 (43%) in UC, OR 1.47 (95% CI: 1.05-2.06) with no difference in antihypertensive drugs. There were no differences in management of cholesterol or glucose. CONCLUSIONS: The EUROACTION preventive cardiology programme in high CVD risk smokers using optional varenicline substantially increased smoking abstinence over 16 weeks and also reduced overall cardiovascular risk compared with UC. REC reference: 09/H0402/85; EudraCT number: 2009-012451-18; http://www.controlled-trials.com/ISRCTN22073647, 12 February 2014, date last accessed.

Passive smoking and smoking cessation among patients with coronary heart disease across Europe: results from the EUROASPIRE III survey.

AIMS: Passive smoking is the inhalation of environmental tobacco smoke (ETS) and is a risk factor for coronary heart disease (CHD). We aimed to describe the frequency of passive smoking among patients with CHD and to investigate the association between ETS exposure and smoking cessation. METHODS AND RESULTS: The EUROASPIRE III survey was conducted in 2006-07 among CHD patients up to 80 years of age from 22 European regions. Patients were interviewed and examined on average 15 months after hospital admission for CHD. Information was obtained on smoking prior to hospital admission, smoking at interview, and ETS exposure at home, at work, and at other locations. Breath carbon monoxide was measured to validate self-reported non-smoking. Among 8729 patients, 6060 (69.4%) were non-smokers prior to hospital admission, of whom 10.3% reported ETS exposure at home, 7.2% at work, and 13.8% at other locations. Overall, 24.2% of non-smokers were exposed to ETS at any place. Among the 2669 patients who were smoking prior to hospital admission, the likelihood of cessation at interview was lower in those with ETS exposure at home than in those without [25.3 vs. 58.1%; adjusted odds ratio (OR) 0.26, 95% confidence interval (CI) 0.20-0.33]. This finding applied also to ETS exposure at work (32.2 vs. 52.7%; adjusted OR 0.56, 95% CI 0.42-0.76) and at other locations (38.0 vs. 52.8%; adjusted OR 0.63, 95% CI 0.48-0.84). CONCLUSION: A noteworthy proportion of non-smokers with CHD are exposed to ETS. Passive smoking may jeopardize smoking cessation among CHD patients.

Challenge of cardiovascular prevention in primary care: achievement of lifestyle, blood pressure, lipids and diabetes targets for primary prevention in England - results from ASPIRE-3-PREVENT cross-sectional survey.

BACKGROUND: Implementation of the cardiovascular disease (CVD) prevention guidelines in the UK has been repeatedly evaluated under the auspices of the British Cardiovascular Society in three Action on Secondary and Primary Prevention by Intervention to Reduce Events (ASPIRE) surveys in 1994-1995, 2008-2010 and 2017-2019. The primary care arm of ASPIRE-2-PREVENT (A-3-P) was conducted to evaluate lifestyle and medical risk factor management in people at high risk of atherosclerotic CVD in everyday clinical practice. METHODS: A-3-P was a cross-sectional survey in 27 general practices and health centres across 5 English National Health Service regions. Patients with no history of atherosclerotic CVD started on blood pressure and/or lipid and/or glucose lowering treatments were identified retrospectively and interviewed at least 6 months after the initiation of medication. RESULTS: 557 patients attended the interview and examination (45.8% women; mean age 61.7±10.8 years). The risk factor control was poor: 9.3% of patients were smokers, 38.1% obese (body mass index≥30 kg/m2) and 53.5% centrally obese (waist circumference≥88 cm for women, ≥102 cm for men). Only 37.8% of patients on blood pressure-lowering therapies achieved the target of<140/90 mm Hg. Among treated dyslipidaemic patients, 59.5% reached the low-density lipoprotein cholesterol target of <2.6 mmol/L. 62% of patients with self-reported diabetes mellitus attained the glycated haemoglobin target of <7.0%. CONCLUSION: The results of A-3-P survey show that large proportions of people at high CVD risk have poor control of lifestiles and medical risk factors. There is considerable potential to raise the standards of preventive cardiology care by providing comprehensive, multidisciplinary prevention programmes addressing all aspects of risk factor management to reduce the total risk of future CVD.

Dysglycaemia screening and its prognostic impact in patients with coronary artery disease: experiences from the EUROASPIRE IV and V cohort studies.

BACKGROUND: Glucose perturbations can be detected by fasting plasma glucose (FPG), HbA1c, and the oral glucose tolerance test (OGTT). The highest yield is provided by OGTT. HbA1c is considered more practical. We compare the diagnostic and predictive performance of these glycaemic indicators based on combined data from the EUROASPIRE IV (EAIV) and V (EAV) studies. METHODS: This cohort study was conducted in 79 centres in 24 European countries (EAIV) and 131 centres in 27 European countries (EAV). Eligible patients were aged 18-80 years, did not have diabetes, and were diagnosed with coronary artery disease 6-36 months (EAIV) or 6-24 months (EAV) before the investigation. Patients were investigated with OGTT (FPG and 2 h post-load glucose [2-hPG]) and HbA1c. Follow-up of subsequent cardiovascular events was done by means of a questionnaire at least 1 year after the baseline investigation. Analyses were done in patients with both OGTT and HbA1c data available. Outcome analysis in these patients was restricted to those with valid follow-up data available. FINDINGS: 16 259 patients were interviewed in EAIV (2012-13) and EAV (2016-17). 8364 patients had both OGTT and HbA1C data and were included in the analysis population (3932 in EAIV and 4432 in EAV). Information on cardiovascular events was available in 7892 patients. Follow-up was for a median 1·6 years (IQR 1·2-2·0). The average patient age was 63·3 years (SD 9·8), and 6346 (75·9%) of 8364 patients were men. At baseline, 1856 (22·5%) of 8263 patients were determined to have newly detected type 2 diabetes using OGTT alone, compared with 346 (4·2%) using HbA1c alone. New dysglycaemia, defined as newly detected type 2 diabetes or impaired glucose tolerance (IGT), was present in 3896 (47·1%) of the patients according to 2hPG. 2hPG 9 mmol/L or greater (162 mg/dL, adjusted hazard ratio [aHR] 1·58; 95% CI 1·27-1·95, p<0·0001), and HbA1c 5·9% or greater (41 mmol/mol, aHR 1·48, 1·19-1·84; p=0·0010) were the strongest predictors of cardiovascular events, while FPG did not predict. A multivariable model showed that the effect of HbA1c on cardiovascular events was mainly explained by 2hPG (aHR for 1 unit increase in HbA1c 1·13, 0·98-1·30; p=0·11; and aHR for 1 unit increase in Ln[2hPG] 1·37, 1·08-1·74; p=0·0042). INTERPRETATION: 2hPG appears better than HbA1c in detecting dysglycaemia and predicting its impact on future cardiovascular events in patients with coronary artery disease and should be recommended as the primary screening tool. FUNDING: Swedish Heart-Lung Foundation, Region Stockholm (ALF), the Erling Persson Foundation, the Baltic Child Foundation.

Cost-effectiveness of optimizing prevention in patients with coronary heart disease: the EUROASPIRE III health economics project.

AIMS: The EUROASPIRE III survey indicated that the guidelines on cardiovascular disease prevention are poorly implemented in patients with established coronary heart disease (CHD). The purpose of this health economic project was to assess the potential clinical effectiveness and cost-effectiveness of optimizing cardiovascular prevention in eight EUROASPIRE III countries (Belgium, Bulgaria, Croatia, Finland, France, Italy, Poland, and the U.K.). METHODS AND RESULTS The individual risk for subsequent cardiovascular events was estimated, based on published Framingham equations. Based on the EUROASPIRE III data, the type of suboptimal prevention, if any, was identified for each individual, and the effects of optimized tailored prevention (smoking cessation, diet and exercise, better management of elevated blood pressure and/or LDL-cholesterol) were estimated. Costs of prevention and savings of avoided events were based on country-specific data. A willingness to pay threshold of €30,000/quality-adjusted life year (QALY) was used. The robustness of the results was validated by sensitivity analyses. Overall, the cost-effectiveness analyses for the eight countries showed mainly favourable results with an average incremental cost-effectiveness ratio (ICER) of €12,484 per QALY. Only in the minority of patients at the lowest risk for recurrent events, intensifying preventive therapy seems not cost-effective. Also, the single impact of intensified cholesterol control seems less cost-effective, possibly because their initial 2-year risk was already fairly low, hence the room for improvement is rather limited. CONCLUSION: These results underscore the societal value of optimizing prevention in most patients with established CHD, but also highlight the need for setting priorities towards patients more at risk and the need for more studies comparing intensified prevention with usual care in these patients.

Dietary management of patients at high risk for cardiovascular disease; EUROASPIRE V.

BACKGROUND: Dietary prevention of cardiovascular risk factors is seldom implemented. AIM: We assessed the dietary changes made by subjects at high risk of cardiovascular disease (CVD). DESIGN AND SETTING: Cross-sectional, multicentre observational study (European Society of Cardiology - ESC EORP-EUROASPIRE V Primary Care) including 78 centres from 16 ESC countries. METHODS: Participants aged 18-79 years, devoid of CVD but treated with antihypertensive and/or lipid-lowering and/or antidiabetic therapy were interviewed >6 months and <2 years after medication initiation. Information regarding dietary management was collected by questionnaire. RESULTS: 2759 participants (overall participation rate 70.2%, 1589 women, 1415 aged ≥60 years, 43.5% with obesity, 71.1% on antihypertensive, 29.2% on lipid-lowering and 31.5% on antidiabetic treatment). Among participants with obesity, 47.7% reported having received dietary advice to lose weight [range: 24.7% (Greece) to 71.8% (Lithuania)]. Among participants on antihypertensive drug therapy, 53.9% reported being on a blood pressure lowering diet [range: 5.6% (UK) to 90.4% (Greece)]; a reduction of salt intake in the last three years was reported by 71.4% [range: 12.5% (Sweden) to 89.7% (Egypt)]. Among participants on lipid-lowering therapy, 56.0% reported being on a lipid lowering diet [range: 7.1% (Sweden) to 90.3% (Egypt)]. Among participants with diabetes, 57.2% reported being on a diet [range: 21.6% (Romania) to 95.1% (Bosnia & Herzegovina)]; a reduction in sugar intake was reported by 80.8% [range: 56.5% (Sweden) to 96.7% (Russian Federation)]. CONCLUSIONS: In ESC countries, fewer than 60% of participants at high CVD risk report being on a specific diet, with wide differences between countries.