Time trends in risk factor control and use of secondary preventive medication among patients with myocardial infarction attending cardiac rehabilitation: data from the SWEDEHEART registry 2006–2017

Background Systematically monitoring results within cardiac rehabilitation (CR) has been highlighted as a possible way to improve CR outcomes. The nationwide SWEDEHEART registry has monitored quality of care post myocardial infarction (MI) in Sweden since the 1990s. Follow-up data describing treatment and outcomes within CR has been collected since 2006. Purpose To describe changes in risk factor control and use of secondary preventive medication for post MI patients after completion of CR in Sweden 2006–2017, and to compare with trends in the EUROASPIRE surveys. Methods All patients who suffered an MI and attended a one-year CR follow-up visit registered in SWEDEHEART 2006–2017 were included (n=66 666, 18–74 years, 75% men). Trends in risk factor control and secondary preventive medication were collected yearly and analyzed over the time period using Cochran-Armitage trend test. Comparisons were made to data from the EUROASPIRE III (2006–2007), IV (2012–2013) and V (2016–2017) surveys, where patients with coronary artery events or interventions were interviewed at approximately 1.2 years after the index event (n=25 225, 18–80 years, 74% men). Results Trends in blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) control, smoking, and central obesity are shown in the Figure. The proportion of patients achieving BP goal <140/90 mmHg and LDL-C goal <1.8 mmol/L increased by 16% and 29% from 2006 to 2017 in SWEDEHEART (p for trend <0.0001 for both), compared to 14% and 8% between EUROASPIRE III and V. Of patients who were active smokers at the time of the index event, the proportion still smoking at one-year remained unchanged in SWEDEHEART (43% in 2006 and 2017) while increasing from 52% to 55% in the EUROASPIRE surveys. An increase in prevalence of central obesity from approximately 50% to 60% was observed in both cohorts. The proportion of patients with obesity (BMI ≥30kg/m2) and diabetes increased in SWEDEHEART during the observed period from 23% to 29% (obesity) and 18% to 25% (diabetes) (p for trend <0.0001 for both). The proportions in 2017 were considerably lower than in EUROASPIRE V (2016–2017), where 38% were obese and 29% had diabetes. The use of statins increased from 89% to 93%, ezetimibe from 5% to 21%, and ACE/ARB from 65% to 82% in SWEDEHEART (p for trend <0.0001 for all). In comparison, in EUROASPIRE V the proportion treated with lipid lowering medication of any kind was 84% and with ACE/ARB was 75%. Conclusion Between 2006–2017, considerable improvements were achieved in risk factor control and use of secondary preventive medication for MI patients completing CR in Sweden, where all patients were monitored through the SWEDEHEART registry. The improvements were larger than observed in the EUROASPIRE surveys during the same time period. Continuous and nationwide auditing of CR outcomes, as well as local review of performance, could be possible explanations for some of the observed differences. Figure 1 Funding Acknowledgement Type of funding source: None

Care management of patients with high cardiovascular risk in Hungary an international and Hungarian longitudinal comparison of target level achievement

Background Patients with high cardiovascular risk are usually cared for in primary care settings. Assessment of the effectiveness of long-time care was a subject of many European studies in the last two decades. This paper aims to present two Hungarian primary care cross sectional surveys and to compare their results to the primary care arms of the European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) III. and IV. studies. Methods Between 2010 and 2011, 679 patients with high cardiovascular risk were recruited in 20 Hungarian primary care practices and 628 patients were selected in 40 practices between 2015 and 2016. The actual national recommendations were used for classification, all based on European guidelines. Achievements of target levels for blood pressure, total-, LDL-and HDL-cholesterols, triglyceride, and HbA1c (in diabetics) were recorded and analyzed. Further cardiovascular risk factors, such as smoking, BMI, waist-circumference were also evaluated. Results There was a statistically significant improvement in the management of blood-pressure and plasma LDL-cholesterol levels among high risk patients, while there was no change in the plasma triglyceride values. The effectiveness of diabetes care deteriorated. In international relation, the management of blood pressure and plasma LDL-cholesterol values were better in Hungary when compared to the results of EUROASPIRE III-IV. studies, while the previous advantage in diabetes care disappeared. A higher proportion of diabetic patients was above the target values in Hungary than the means of the European surveys. There was a higher proportion of smokers in the Hungarian samples, while the proportion of obese and overweight patients was similar to the European sample. Conclusions Primary care has a unique role in cardiovascular prevention. Although many of the patients are managed appropriately, there is a need to improve primary care services in Hungary, giving more competences to GPs in prescription and introducing structural changes in the healthcare system.

To what extent can the chosen blood pressure measurement technique affect the outcomes of an observational survey?

Aim: We analyzed to what extent measurement protocol influenced individual blood pressure (BP) and achievement of treatment target in patients with coronary heart disease. Methods: In a subsample of Czech EUROASPIRE III–V survey participants (n = 913), we compared the per-protocol BP measurement (by automated oscillometric device OMRON at the beginning of survey procedure) with control auscultatory measurement (by physician during interview). Results: Per-protocol approach produced significantly (p < 0.0001) higher BP values (by 9/6 mmHg in median) than auscultatory measurements and led to markedly higher proportion of patients over target BP (less than 140/90 mmHg; 59.3 vs 34.9% [p < 0.0001], per-protocol vs auscultatory technique, respectively). Conclusion: Per-protocol oscillometric technique was not equivalent to conventional auscultatory measurement and seriously over-rated the real nonachievement of BP target in observational surveys.

Recent progress in the management of atherosclerosis and hyperlipidemia

Despite the positive trend over the last decade, mortality from the circulatory system diseases in the Russian Federation remains high: in 2016, 616 cases per 100 thousand people were registered, with an absolute loss of about 900 thousand people, of whom nearly 50% died from coronary artery disease (CAD). Atherosclerosis plays a critical role in the development of cardiovascular disease, as the damage to the arterial bed begins early - already at a young age. The major modifiable risk factors for atherosclerosis are hyperlipidemia, hypertension, diabetes, smoking. The leading risk factor for coronary atherosclerosis is lowdensity lipoprotein cholesterol (LDL-C). According to EUROASPIRE III, in Russia, hypercholesterolemia is found in 65% of patients with CAD (LDL-C above 3 mmol/l). According to many large randomized trials and meta-analyses, there is evidence that statins which constitute the major class of lipid-lowering drugs are effective in the reduction of LDL-C in both primary and secondary prevention of cardiovascular events.

Regular exercise behaviour and intention and symptoms of anxiety and depression in coronary heart disease patients across Europe: Results from the EUROASPIRE III survey

Background Regular exercise lowers the risk of cardiovascular death in coronary heart disease (CHD) patients. We aimed to investigate regular exercise behaviour and intention in relation to symptoms of anxiety and depression in CHD patients across Europe. Design This study was based on a multicentre cross-sectional survey. Methods In the EUROpean Action on Secondary and Primary Prevention through Intervention to Reduce Events (EUROASPIRE) III survey, 8966 CHD patients <80 years of age from 22 European countries were interviewed on average 15 months after hospitalisation. Whether patients exercised or intended to exercise regularly was assessed using the Stages of Change questionnaire in 8330 patients. Symptoms of anxiety and depression were evaluated using the Hospital Anxiety and Depression Scale. Total physical activity was measured by the International Physical Activity Questionnaire in patients from a subset of 14 countries. Results Overall, 50.3% of patients were not intending to exercise regularly, 15.9% were intending to exercise regularly, and 33.8% were exercising regularly. Patients with severe symptoms of depression less frequently exercised regularly than patients with symptoms in the normal range (20.2%, 95% confidence interval (CI) 14.8–26.8 vs 36.7%, 95% CI 29.8–44.2). Among patients not exercising regularly, patients with severe symptoms of depression were less likely to have an intention to exercise regularly (odds ratio 0.62, 95% CI 0.46–0.85). Symptoms of anxiety did not affect regular exercise intention. In sensitivity analysis, results were consistent when adjusting for total physical activity. Conclusions Lower frequency of regular exercise and decreased likelihood of exercise intention were observed in CHD patients with severe depressive symptoms. Severe symptoms of depression may preclude CHD patients from performing regular exercise.