ESC-EORP EUROASPIRE Research Articles

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

Dietary prevention of cardiovascular risk factors is seldom implemented. We assessed the dietary changes made by subjects at high risk of cardiovascular disease (CVD). Cross-sectional, multicentre observational study (European Society of Cardiology - ESC EORP-EUROASPIRE V Primary Care) including 78 centres from 16 ESC countries. 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. 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)]. In ESC countries, fewer than 60% of participants at high CVD risk report being on a specific diet, with wide differences between countries.

Gender differences in risk factor management and pharmacological treatment among CHD patients: Belgian results of the EUROASPIRE IV and EUROASPIRE V surveys

Aims The aim of this study was to provide an up-to-date overview of gender differences or similarities in risk factor control and medical management in the Belgian CHD population. Methods All analyses are based on the ESC EORP EUROASPIRE IV and EUROASPIRE V (European Survey Of Cardiovascular Disease Prevention And Diabetes) surveys. Patients between 18 and 80 years old, hospitalised for a first or recurrent coronary event, were included in the survey. Results Data were available for 10,519 patients, of which 23.9% were women. Women had a worse risk factor profile compared to men. Women were more physical inactive (OR = 1.31, 95% CI = 1.19–1.44), had a higher prevalence of obesity (OR = 1.37, 95% CI = 1.25–1.50) and had a worse LDL-C control (OR = 1.52, 95% CI = 1.36–1.70). Moreover, women were less likely to use ACE-I/ARBs (OR = 0.84, 95% CI = 0.76–0.94) and statins (OR = 0.79, 95% CI = 0.70–0.90). In addition, little gender differences were found in patients’ risk factor awareness, except on cholesterol awareness. Women were more aware about their total cholesterol levels (OR = 1.37, 95% CI = 1.21–1.56). Conclusion Despite little to no gender differences in the management of CHD patients, women still have a worse risk factor profile, both in Belgian and in other European high-income countries.

Gender differences in health-related quality of life and psychological distress among coronary patients: Does comorbidity matter? Results from the ESC EORP EUROASPIRE V registry

AimsThis study aimed to provide an overview on contemporary gender differences in HRQoL/psychological distress and their relationship with comorbidity burden among European coronary heart disease (CHD) patients. MethodsAnalyses were based on the cross-sectional ESC EORP EUROASPIRE V survey. Consecutive patients (aged 18–80 years), hospitalized for a first or recurrent coronary event were included in this study. Data at hospital discharge and at follow-up (6 to 24 months after hospitalisation) were collected. ResultsData were available for 8261 patients of which 25.8% women. Overall, women reported a worse EQ-5D-5L index score (0.73 vs. 0.81; P < 0.001), EQ-VAS (63.1 vs. 66.0; P = 0.001), global HeartQoL (1.94 vs. 2.26; P < 0.001), physical HeartQoL (1.96 vs. 2.30; P < 0.001), emotional HeartQoL (1.88 vs. 2.18; P < 0.001), HADS-A (6.69 vs. 4.99; P < 0.001), and HADS-D (5.73 vs. 4.62; P < 0.001) compared to men. Also, women were more likely to have comorbidities compared to men (1 comorbidity: 38.7% vs. 35.0%, 2 comorbidities: 9.7% vs. 7.5%; P < 0.001). There is indication that heart failure (EQ-VAS) and diabetes (global HeartQoL, emotional HeartQoL, physical HeartQoL, and HADS-D) interacted with gender and modulate the relationship with HRQoL, in disfavour of women. ConclusionSubstantial gender-based health inequalities in terms of HRQoL and psychological distress were found, in disfavour of women. Women had worse HRQoL and psychological distress outcomes when having comorbidities. To a limited extent, comorbidity and women had a negative/synergistic effect on HRQoL. Special attention should be given to this population groups within daily clinical practice.

Assessing the probability of risk factor control in patients with coronary heart disease: results from the ESC-EORP EUROASPIRE V survey.

In patients with coronary heart disease (CHD), we investigated whether it is possible to accurately assess the probability of short-term control of risk factors (blood pressure, cholesterol, smoking) based on individual and large-area residential characteristics. We merged individual data of participants from EUROASPIRE V who were hospitalized for CHD (2014-2017) and interviewed and examined for risk factor control (2016-2017), with large-area residential data provided by Eurostat for Nomenclature of Territorial Units for Statistics (NUTS) regions using postal codes. Data from 2562 CHD patients in 16 countries were linked to data from 60 NUTS 2 and 121 NUTS 3 regions. The median time between hospitalization and interview was 14 months. We developed prediction models to assess the probability of risk factor control at interview using data from the time of hospitalization: (i) baseline models including 35 variables on patients' demographic, clinical, and socio-economic characteristics and (ii) extended models additionally considering nine variables on large-area residential characteristics. We calculated and internally validated c-indices to assess the discriminative ability of prediction models. Baseline models showed good discrimination with c-indices of 0.69, 0.70, and 0.76 for blood pressure control, cholesterol control, and smoking cessation, respectively. Extended models for blood pressure, cholesterol, and smoking yielded improved c-indices of 0.72, 0.71, and 0.78, respectively. Our results indicate that the probability of risk factor control in CHD patients can be accurately assessed using individual and large-area residential characteristics, allowing for an identification of patients who are less likely to achieve risk factor targets.

Gender differences in cardiovascular risk factor awareness. Results from the ESC EORP EUROASPIRE V registry

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Fonds voor hartchirurgie - Fonds pour la Chirurgie Cardiaque Background Risk factor awareness among coronary patients is related to a decreased risk of recurrent coronary events and hence important in the secondary prevention of coronary heart disease (CHD). Whereas previous studies demonstrated gender differences in disfavour of women with regard to patients’ risk factor control, little is known about gender differences in patients’ risk factor awareness. Purpose The aim of this study was to document potential gender differences across Europe in patients’ risk factor awareness and information provided by healthcare professionals. Methods Analyses were based on data from the most recent ESC EORP EUROASPIRE V survey (European Survey Of Cardiovascular Disease Prevention And Diabetes, 2016-17). Consecutive patients hospitalized for a first or recurrent coronary event or surgical procedure between 18-80 years old at the time of identification were retrospectively identified in 27 countries. Awareness of risk factor levels were defined as patients’ self-reported awareness about their latest weight, waist circumference, blood pressure, total cholesterol, blood glucose levels, and HbA1c levels. Data on risk factor awareness and information provided by healthcare professionals were obtained from patient interviews (6 months to 2 years prior to the date of the study visit). Logistic regression analyses were performed adjusting for age and medical history (stroke, heart failure, and diabetes). Results Information was available on 8,261 patients, including 25.8% women. Women were significantly older (65.4 vs. 63.0 years) and were more likely to have a history of stroke (5.3% vs. 3.7%; P=0.002), heart failure (7.6% vs. 5.9%; P=0.006), and self-reported diabetes (33.1% vs. 28.0%; P&amp;lt;0.001). Overall, no significant gender differences were found regarding the information provided by a healthcare professional on overweight, diabetes, and chronic kidney disease, whereas, a higher proportion of women with hypertension (≥140/80 (≥140/85 if diabetes)) (OR=2.07, 95% CI=4.60-2.68) and women with raised cholesterol levels (LDL-C ≥1.8mmol/L) (OR=1.31, 95% CI=1.14-1.51) were informed about their raised risk factor levels. Furthermore, women with obesity were less aware about their actual weight (OR= 0.66, 95% CI=0.52-0.85) and weight target level (OR= 0.66, 95% CI=0.54-0.81) than men. In contrast, no significant gender differences in awareness of waist circumference levels were found in obese patients neither for fasting blood glucose or HbA1c levels in patients with self-reported diabetes. Women with hypertension and those found with raised LDL-C levels were more aware about their target blood pressure level (OR=1.21, 95% CI=1.01-1.46) and actual cholesterol level (OR=1.18, 95% CI=1.02-1.36). Conclusions Our study reveals only little gender differences in disfavour of women in terms of information provided by healthcare professionals and risk factor awareness.

Gender differences in lifestyle management among coronary patients and the association with education and age: results from the ESC EORP EUROASPIRE V registry.

Lifestyle management is essential in the secondary care of coronary heart disease (CHD) patients. Little evidence is available about gender differences in lifestyle counselling and lifestyle compliance. This study aimed to provide an overview on potential gender differences in lifestyle advice provided by a healthcare professional and patients' lifestyle compliance. Analyses were based on the cross-sectional ESC EORP EUROASPIRE V survey including data on CHD patients across 27 European countries. Consecutive patients &lt;80 years, hospitalized for a first or recurrent coronary event, were included in the study. Information on lifestyle management was collected from medical records, medical examination, and structured questionnaires during patient interviews (≥6 months to &lt;2 years after hospitalization). Data were available for 8261 patients of whom 25.8% women. Overall, no gender differences were observed in lifestyle advice provided by a healthcare professional for smoking cessation advice, dietary advice, advice on losing weight, and physical activity advice (P &gt; 0.05). However, a closer look at the particular actions to adopt a healthy diet revealed that women reported more frequently a reduction of their salt (68.6% vs. 73.7%; P = 0.002), fat (70.8% vs. 74.7%; P = 0.003), and calorie intake (56.8% vs. 60.5%; P = 0.004) compared to men. In contrast, women were less likely to increase their physical activity levels (55.5% vs. 48.0%; P &lt; 0.001). Despite little gender differences in lifestyle advice provided by a healthcare professional, lifestyle compliance for physical activity is worse in CHD women. Further actions are needed to increase physical activity levels in female CHD patients.

Gender differences in cardiovascular risk factor awareness: Results from the ESC EORP EUROASPIRE V Registry

BackgroundPatients' risk factor awareness is essential to decrease the risk of recurrent coronary events. The aim of this study was to provide up-to-date evidence on existing gender differences in the patients' knowledge of risk factors and information provided by healthcare professionals. MethodsAnalyses were based on the cross-sectional ESC EORP EUROASPIRE V survey, including data on CHD patients across 27 European countries. Consecutive patients (18–80 years), hospitalized for a coronary event or surgical procedure, were retrospectively identified. Information on risk factor awareness was collected from medical records, medical examination, and structured questionnaires during the study visit (six months to two years after hospitalization). ResultsPatient information was available for 8261 patients, of which 25.8% were women. Although women with obesity were significantly less aware about their actual (OR = 0.66, CI = 0.52–0.85) and target weight levels (OR = 0.66, CI = 0.54–0.81), no significant gender differences in risk factor awareness were found in disfavour of women. Remarkably, women with hypertension and women with raised low-density lipoprotein cholesterol (LDL-C) levels were even more aware about their target blood pressure levels (OR = 1.21, CI = 1.01–1.46) and actual cholesterol levels (OR = 1.18, CI = 1.02–1.36), respectively. Moreover, there is some indication that women were more informed by a healthcare professional if they had raised CHD risk factor levels. ConclusionsOur study showed only few gender differences in disfavour of women in terms of risk factor awareness and information provided by a healthcare professional. Nevertheless, previous EUROASPIRE V findings demonstrated that women still have a poorer risk factor control in secondary CHD prevention.

Saving time by replacing the standardised two-hour oral glucose tolerance test with a one-hour test: Validation of a new screening algorithm in patients with coronary artery disease from the ESC-EORP EUROASPIRE V registry

AimsAn oral glucose tolerance test (OGTT) combining fasting (FPG) and 2-hour plasma glucose (2hPG) is the most sensitive method for detecting type 2 diabetes (T2DM). Since it is considered time-consuming, we aim at validating a previously proposed screening algorithm based on a 1-hour plasma glucose (1hPG) with a 12 mmol/L threshold. MethodsNine-hundred-eighteen patients with coronary artery disease (CAD) without known T2DM from the EUROASPIRE V cross-sectional survey underwent an OGTT. The reference for T2DM was 2hPG ≥ 11.1 mmol/L. T2DM diagnosis by HbA1c ≥ 6.5%(48 mmol/mol), FPG ≥ 7.0 mmol/L, and 1hPG ≥ 12 mmol/L were compared with the outcome of 2hPG. ResultsMean FPG, HbA1c and 2hPG were 6.1 mmol/L, 5.6%(38 mmol/mol) and 7.8 mmol/L respectively. Ninety-six patients (10%) were diagnosed with T2DM according to 2hPG. Using this definition, in the group with FPG < 6.5 mmol/L and 1hPG < 12 only 5 (1%) were misdiagnosed as false negatives. All patients with a FPG > 8.0 mmol/L and 1hPG > 15.0 mmol/L were identified as having T2DM. According to the algorithm, in 79% of patients T2DM could be excluded by combining FPG < 6.5 mmol/L and 1hPG < 12 mmol/L. ConclusionsT2DM Screening by means of an algorithm combining FPG and 1hPG limits the demand of a 2hOGTT in 79% of CAD patients without known T2DM. HbA1c did not add to the information derived from this algorithm.

Gender differences in health-related quality of life among coronary patients and the relation with comorbidity burden. Results from the ESC EORP EUROASPIRE V survey

Abstract Background Impaired health-related quality of life (HRQoL) is related to increased morbidity and mortality among coronary heart disease (CHD) patients. Although gender differences in HRQoL have been observed in the general population, the magnitude of gender differences tends to be more pronounced in CHD patients. In addition, a higher comorbidity burden, common in CHD patients, is known to result in an even worse HRQoL outcome. Purpose The aim of this study is to evaluate HRQoL- gender differences among CHD patients and to explore its relationship with comorbidity burden. Methods Analyses were based on the most recent ESC EORP EUROASPIRE V survey data, including patient information from 27 European countries. Consecutive patients (18–80 years), hospitalized for a coronary event or surgical procedure were recruited in the survey. Data presented here were obtained from medical records and standardized patient interviews (6 months to 2 years following hospital discharge). Mean EQ-5D-5L index scores were used to evaluate patients' self-reported health status. A history of stroke, heart failure, peripheral artery disease (PAD), chronic kidney disease (CKD), and self-reported diabetes were considered as comorbidities. Generalized linear mixed models were fitted accounting for clustering of patients within countries and adjusted for age. To investigate the interplay of gender with comorbidities, two-way interaction terms were included. Results Data was available for 8,261 patients, including 25.8% women. Women were slightly older than men (65.4 vs 63.0 years) and more likely to have a history of stroke (5.3% vs. 3.7%; p=0.04), heart failure (7.6% vs. 5.9%; p=0.02), and self-reported diabetes (33.1% vs. 28.0%; p&amp;lt;0.001). No significant differences were seen in the prevalences of PAD (2.5% vs. 2.7%; p=0.25) and CKD (13.8% vs. 14.5%; p=0.47). Overall, women reported a worse EQ-5D-5L index score compared to men (0.73 vs. 0.81; p&amp;lt;0.001). Also, considering CHD patients without comorbidities, women reported a worse EQ-5D-5L index score (0.77 vs. 0.84; p&amp;lt;0.001). Stratification by comorbidities revealed that the EQ-5D-5L index score differed substantially between genders. Although no gender differences were found for patients with PAD (0.62 vs. 0.68; p=0.13), women reported a worse EQ-5D-5L index score if having a history of stroke (0.59 vs. 0.69; p&amp;lt;0.001), heart failure (0.64 vs. 0.71; p=0.01), CKD (0.76 vs. 0.81; p&amp;lt;0.001), and self-reported diabetes (0.69 vs. 0.78; p&amp;lt;0.001). Moreover, detailed analyses revealed a significant interaction between gender and self-reported diabetes (p=0.04) and gender and CKD (p=0.04) in favour of women. A closer look at the combination of comorbidities revealed no significant interactions possibly due to the smaller number of patients. Conclusion Women reported a worse HRQoL compared to men. Further quantitative and qualitative research is needed to understand the gender-differential in HRQoL. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Fonds voor hartchirurgie - Fonds pour la Chirurgie Cardiaque

Lifestyle management and compliance in coronary patients: The gender gap. Results from the ESC EORP EUROASPIRE V survey

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Fonds voor hartchirurgie - Fonds pour la Chirurgie Cardiaque OnBehalf EUROASPIRE studygroup BACKGROUND Although previous EUROASPIRE (European Survey Of Cardiovascular Disease Prevention And Diabetes) findings suggest only limited gender differences in the medication intake of coronary patients, the CVD risk factor profile in women remains suboptimal compared to men. Therefore, to further lower the risk of subsequent cardiovascular events, lifestyle behaviour in secondary prevention is crucial. Little is known about gender differences in prescribed lifestyle and patient compliance in tackling lifestyle related risk factor targets. PURPOSE The aim of this study is to identify gender differences in lifestyle prescription and lifestyle compliance after a coronary event. METHODS Analyses were carried out on the ESC EORP EUROASPIRE V survey data, including information from coronary patients recruited in 27 European countries. Consecutive patients &amp;lt;80 years were hospitalized for a CABG, PCI, acute myocardial infarction or acute myocardial ischaemia. Information on lifestyle prescription and lifestyle compliance, were obtained from standardized patient interviews (6 months to 2 years following hospital discharge). Logistic regression analyses adjusting for medical history (stroke, heart failure and diabetes) were performed. RESULTS Data was available for 8261 patients of which 25.8% were women. The mean (SD) age at interview was 62.9 (9.7) years for men and 65.4 (9.2) for women. Overall, no gender differences were observed in smoking cessation advice (85.2% vs. 84.5%; P = 0.90) and in smokers’ attempts to quit smoking (62.6% vs. 63.9%; P= 0.58). Also, no gender differences were observed in dietary advice (85.5% vs. 84.9%; P= 0.32) and in attempts to adopt a healthier diet (87.1% vs. 88.4%; P= 0.14). In contrast, although no gender differences were seen in weight changes among obese patients (60.1% vs. 58.2%; P = 0.49), women were less likely to receive advice on losing weight (75.1% vs. 71.6%; P = 0.02). Interestingly, the latter findings were driven by educational level. Women with a low education level were less likely to receive weight loss advice (71.8% vs. 52.9%; P &amp;lt; 0.001) and a lower proportion of them tried to lose weight (52.3% vs. 36.7%; P &amp;lt; 0.001), while no significant differences were observed in those with a high educational level. Furthermore, women were less likely to receive physical activity advice (63.8% vs. 59.6%; P &amp;lt; 0.001) and a lower proportion of them attempted to increase their physical activity levels (55.5% vs. 48.0%; P &amp;lt; 0.001). CONCLUSION These findings suggest worse lifestyle prescription and lifestyle changes for physical activity in women and worse weight loss prescription and weight loss compliance in low educated but not highly educated women. Specific attention should be given to women with a low educational level. Further quantitative and qualitative research is needed to understand the gender gap in lifestyle management.

Poor attainment of LDL-cholesterol target in patients at high cardiovascular risk: a report from the ESC EORP EUROASPIRE V survey in 16 European countries

Background and Aims: EUROASPIRE V was carried out by the ESC-EORP programme, aiming to determine whether the 2016 Joint European Societies’ guidelines on cardiovascular disease (CVD) prevention for management of LDL-cholesterol in people at high risk of developing CVD have been implemented in clinical practice

Alcohol consumption patterns across Europe and adherence to the European guidelines in coronary patients: findings from the ESC-EORP EUROASPIRE V survey

Abstract Introduction Alcohol consumption is an important risk factor for cardiovascular morbidity and mortality worldwide. The highest levels of alcohol consumption are observed in Europe, where alcohol as contributing cause of coronary heart disease (CHD) is also most significant. Purpose To describe patterns of alcohol consumption across different European regions and adherence to the current drinking guidelines in coronary patients with a recent CHD. Methods The EUROASPIRE V survey has been conducted in 2016–2017 at 131 centers in 27 European countries in 9,018 patients with a recent CHD. Median alcohol consumption, as well as the proportions abstainers and excessive drinkers (i.e. &amp;gt;70 grams of alcohol per week for women and &amp;gt;140 grams per week for men, as recommended by the European guidelines on cardiovascular prevention), were calculated for each European region (Eastern, Southern, Northern and Western Europe). To assess adherence to guidelines, proportions of participants who were advised to reduce excessive alcohol consumption, as well as the participants who were incorrectly not advised were calculated per European region. Results Mean age was 64 years (sd=9.5), 75% was male. Abstention rates were 51% in males and 74% in females, whereas excessive drinking was reported by 10% of the males (highest in Western Europe (18%) and lowest in Eastern Europe (5%)) and 6% of the females (also highest in Western Europe (12%) and lowest in Eastern Europe (1.4%)). Overall, 57% of the participants were advised to reduce alcohol consumption. In the total population, 3% was incorrectly not advised (Figure 1), but this percentage differed by region with 9% in Western Europe as compared to 1% in Eastern Europe. In regions where alcohol consumption was highest, participants were less often advised to reduce their consumption. Conclusion In this EUROASPIRE V survey the majority of patients with a recent CHD adhere to the current drinking guidelines and only a fraction of the population was incorrectly not advised to reduce consumption. However, substantial heterogeneity exists between European regions. Figure 1. Distribution of advice given per region Funding Acknowledgement Type of funding source: None

Poor attainment of blood pressure, lipids and diabetes targets in people at high cardiovascular risk in Europe: a report from the ESC-EORP EUROASPIRE V Survey in 16 European countries

Abstract Introduction The EUROASPIRE V survey in primary care was carried out by the European Society of Cardiology, EURObservational Research Programme in 2017–2018 and investigated the risk factor management in patients at high cardiovascular (CVD) risk in16 European countries. Purpose To provide an audit the implementation of the 2016 Joint European Societies' guidelines on CVD prevention in people at high risk of developing CVD in primary care and to see whether the practice of preventive cardiology had improved by comparison with the previous EUROASPIRE IV survey in 2014–2015. Methods All patients were free of coronary or other atherosclerotic diseasebut considered at high CVD risk since they had been started on blood pressure and/or lipid and/or glucose lowering treatments. They were interviewed and examined by means of standardized methods ≥6 months after the start of therapy. Results 2,759high CVD risk individuals (58% females), mean age 59 (SD 12) years, were interviewed and examined (participation rate 70%). The risk factor control was very poor, with less than half (47%) of patients on blood pressurelowering medication reaching the target of &amp;lt;140/90 mmHg (&amp;lt;140/85 mmHg in people with self-reported diabetes). Among treated dyslipidaemic patients only 47% attained LDL-cholesterol target of &amp;lt;2.6 mmol/L. Among treated type 2 diabetic patients, 65% achieved the HbA1c target of &amp;lt;7.0mmol/L. However, many patients on no antihypertensive or lipid-lowering medications had elevated blood pressure (43%) and elevated LDL-cholesterol (81%), respectively. The use of blood pressure lowering medication in people with hypertension was: ACE inhibitors/ARBs 79%, beta-blockers 37%, diuretics 36% and calcium channel blockers 32%; with 42% on one, 34% on two, 18% on three and 6% on ≥4 blood pressure lowering drugs. Among people on lipid-lowering medication, statins were prescribed in 97% and fibrates in 3%. Less than two-thirds of patients reported complete adherence with the intake of their blood pressure and lipid-lowering medications. The comparison with EUROASPIRE IV in the same centres that took part in both surveys showed no change in the BP management. There was a slight improvement in the control of LDL-cholesterol and glucose in patients with diabetes. Conclusions The results of EUROASPIRE V clearly demonstrate that the control of blood pressure, LDL-cholesterol and diabetes in patients at high CVD risk remains poor with large proportions not achieving the targets defined in the prevention guidelines. There is a considerable potential to raise the standards of preventive cardiology and to improve the management of patients at high CVD risk in Europe. Funding Acknowledgement Type of funding source: Other. Main funding source(s): European Society of Cardiology

Predicting risk factor control in patients with coronary heart disease using patients' individual and large-area residential characteristics: results from the ESC-EORP EUROASPIRE V survey

Abstract Introduction The impact of small-area residential characteristics on the development of coronary heart disease (CHD) and cardiovascular risk factors is well established. Evidence is so far lacking on the predictive value of large-area residential characteristics for cardiovascular risk. Purpose In CHD patients, we aimed to study the predictive value of large-area residential characteristics beyond patients' individual characteristics for the control of major cardiovascular risk factors (blood pressure, cholesterol and smoking). Methods Patients hospitalised for coronary events or interventions from 16 European countries were interviewed and examined for risk factor control (EUROASPIRE V survey). Based on patients' postal codes, we merged individual patient data with large-area residential data routinely provided by Eurostat for NUTS regions (Nomenclature of Territorial Units for Statistics). We selected patient characteristics recorded at hospitalisation (2015–16) and socioeconomic characteristics of their residential NUTS 2 and 3 regions (2015–16) to predict risk factor control at interview (2016–17). We developed risk prediction models using multi-level logistic regression: 1) baseline models (BMs) with patient data only and 2) extended models (EMs) with patient data (level 1) and large-area residential data (level 2). We employed multiple imputation to overcome sparse data and internally validated results using cross-validation. We used the c-index corresponding to the area under the curve as performance measure to assess the discriminative ability of prediction models. Results Data from 2562 CHD patients in 16 countries could be linked to 60 NUTS 2 and 121 NUTS 3 regions by postal codes. Median time between hospitalisation and interview was 14 (range 6 to 28) months. BMs included 34 patient variables, covering demographic, socioeconomic and clinical characteristics, and EMs additionally included 11 regional socioeconomic variables concerning gross domestic product, income, education, occupation, population density, and health care. For blood pressure control, BMs and EMs showed validated c-indices ranging from 0.71 to 0.73 and from 0.73 to 0.77, respectively. Analyses for cholesterol control yielded c-indices ranging from 0.69 to 0.70 in BMs and from 0.71 to 0.73 in EMs. For smoking cessation, the c-indices ranged from 0.80 to 0.84 in BMs and from 0.83 to 0.84 in EMs. Conclusions Prediction models based on CHD patients' individual characteristics showed a high discriminative ability regarding the control of major cardiovascular risk factors. Further consideration of large-area residential characteristics provided an additive predictive value, markedly increasing the discriminative ability of prediction models for blood pressure and cholesterol control. Socioeconomic characteristics of CHD patients' residential regions can thus help identify patients requiring more intense risk factor management. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): German Heart Foundation

Risk factor management in coronary patients: results from the EUROASPIRE V survey

Abstract Background Previously, there has been a misperception that cardiovascular disease (CVD) mainly affects males. Although lately, there is increasing awareness about the risk of CVD in women, evidence suggests that the management of women with CVD is suboptimal. Purpose The aim of this study is to look at gender differences in treatment and risk factor control after a coronary event across countries with varying income levels. Methods Analyses were based on the ESC-EORP EUROASPIRE V survey, including patient information from 27 European countries. Patients included (18–80 years), were hospitalised for an ischaemic coronary event. Information on medical treatment, risk factors and behavioural changes were obtained during patient interviews (6 months to 2 years after hospitalization). Findings on treatment and risk factor control were compared with the European guidelines on CVD prevention (2016). Country classification by income level (low/medium income vs. high income) was done according to the World Bank Atlas method. Logistic regression analyses adjusted for sex, age, education level, country income, surgical intervention, stroke, heart failure and diabetes were performed. Results Data from 8261 coronary patients, of which 25.8% women, were included in the analyses. Mean (SD) age at the interview was 62.95 (9.72) years for men and 65.36 (9.21) years for women. First, when looking at the evidence based medication intake, no gender differences were seen in the prescription of antiplatelets/aspirin, whereas statins were more often prescribed in men (82.8% vs. 77.7%; p=0.002). A closer look by country income revealed that this difference is entirely due to the higher statin use among men from low/medium income countries (79.6% vs. 72.3%; p=0.004). Second, the risk factor profile differed substantially between genders. Overall, a worse risk factor profile was seen in women. Although, men were more likely to smoke (20.7% vs. 12.8%; p&amp;lt;0.001), women were less physically active (63.2% vs. 72.5%; p&amp;lt;0.001), had more obesity (34.9% vs. 45.7%; p&amp;lt;0.001) and central obesity (51.8% vs. 78.0%; p&amp;lt;0.001), and had a worse lipid control (65.9% vs. 74.3%; p&amp;lt;0.001). Overall, no gender differences were seen in diabetes prevalence and blood pressure control. A closer look at country income level showed that the gender difference in smoking prevalence dissolved in high income countries. In addition, women in low income countries were more likely to suffer from diabetes (26.7% vs. 38.9%; p&amp;lt;0.001). Conclusion These findings suggest a worse risk factor profile in women despite little to no gender differences in medical treatment. Further research is needed to understand the gender-differential in risk factor control. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Fonds voor hartchirurgie - Fonds pour la Chirurgie Cardiaque

Medical Treatment in Coronary Patients: Is there Still a Gender Gap? Results from European Society of Cardiology EUROASPIRE V Registry.

This study is aimed at investigating gender differences in the medical management of patients with coronary heart disease (CHD). Analyses were based on the ESC EORP EUROASPIRE V (European Survey Of Cardiovascular Disease Prevention And Diabetes) survey. Consecutive patients between 18 and 80years, hospitalized for a coronary event, were included in the study. Information on cardiovascular medication intake at hospital discharge and at follow-up (≥ 6months to < 2years after hospitalization) was collected. 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. The EUROASPIRE V results show only limited gender differences in the medical management of CHD patients. Current findings suggest growing awareness aboutrisk in female CHD patients.

Alcohol consumption patterns across Europe and adherence to the European guidelines in coronary patients: Findings from the ESC-EORP EUROASPIRE V survey

Background and aimsAlcohol consumption is an important risk factor for cardiovascular morbidity and mortality worldwide. The highest levels of alcohol consumption are observed in Europe, where alcohol as contributing cause of coronary heart disease (CHD) is also most significant. We aimed to describe alcohol consumption patterns across European regions and adherence to the current guidelines in patients with a recent CHD event. MethodsThe ESC-EORP survey (EUROASPIRE V) has been conducted in 2016–2017 at 131 centers in 27 European countries in 7350 patients with a recent CHD. Median alcohol consumption, as well as the proportion of abstainers and excessive drinkers (i.e. >70 g/week for women and >140 for men, as recommended by the European guidelines on cardiovascular prevention), was calculated for each region. To assess adherence to guidelines, proportions of participants who were advised to reduce excessive alcohol consumption and participants who were incorrectly not advised were calculated per region. ResultsMean age was 64 years (SD: 9.5), 75% were male. Abstention rates were 53% in males and 77% in females, whereas excessive drinking was reported by 9% and 5% of them, respectively. Overall, 57% of the participants were advised to reduce alcohol consumption. In the total population, 3% were incorrectly not advised, however, this percentage differed per region (range: 1%–9%). In regions where alcohol consumption was highest, participants were less often advised to reduce their consumption. ConclusionIn this EUROASPIRE V survey, the majority of CHD patients adhere to the current drinking guidelines, but substantial heterogeneity exists between European regions.

Dietary measures among patients with coronary heart disease in Europe. ESC EORP Euroaspire V

ObjectiveAssess the dietary recommendations provided to patients hospitalized for a coronary heart disease (CHD) event. DesignCross-sectional, multicentre observational study (ESC EORP Euroaspire V). Methods8261 participants (25.8% women, 9.3% aged<50 years) from 27 countries, 6 to 24 months after hospitalization for a CHD event were included. Participants were asked if they had been advised to reduce salt, fat or sugar intake, change type of fat consumed, and increase consumption of plant stanols/sterols, fruit & vegetables, fish and oily fish. Self-reported changes were recorded. ResultsAdvice to reduce energy intake, salt, fat and sugar was provided to 64.5% [range: 9.2–90.5], 73.2% [38.6–95.2], 77.3% [42.3–95.6] and 67.0% [39.4–93.3] of patients, respectively. Advice to change fat type, increase consumption of plant stanols/sterols, fruit & vegetables, fish and oily fish was provided to 68.3% [33.7–92.3], 36.7% [0.6–75.2], 73.2% [39.2–93.6], 66.5% [8.0–90.8] and 53.5% [3.7–83.3] of patients, respectively. Advices were more frequently provided to patients aged 50 to 69, with a high educational level, or obesity. One-eighth [0–55.0] of patients reported having consulted a dietician. Reductions in energy intake, salt, fat and sugar were reported by 57.7% [4.9–81.0], 69.9% [32.1–85.9], 71.8% [40.4–88.4] and 61.2% [29.0–84.0] of patients, respectively. Changes in fat type and increased consumption of plant stanols/sterols, fruit & vegetables, fish and oily fish were reported by 60.9% [4.9–81.0], 25.8% [0.6–54.1], 69.2% [27.7–88.4], 54.8% [4.0–80.1] and 40.4% [2.0–66.8] of patients, respectively. ConclusionDietary advice is not systematically provided to patients with CHD, and considerable differences exist between European countries.

Percentage low-density lipoprotein-cholesterol response to a given statin dose is not fixed across the pre-treatment range: Real world evidence from clinical practice: Data from the ESC-EORP EUROASPIRE V Study.

Recent European guidelines recommend in patients with atherosclerotic cardiovascular disease to achieve a reduction of low-density lipoprotein-cholesterol of at least 50% if the baseline low-density lipoprotein-cholesterol level is between 1.8 and 3.5 mmol/L. Systematic reviews have associated a given statin/dose combination with a fixed percentage low-density lipoprotein-cholesterol response. Algorithms for detecting cases and estimating the prevalence of familial hypercholesterolaemia often rely on such fixed percentage reductions. We used data from 915 coronary patients participating in the EUROASPIRE V study in whom atorvastatin or rosuvastatin therapy was initiated at hospital discharge and who were still using these drugs at the same dose at a follow-up visit 6 or more months later. Pre and on-treatment low-density lipoprotein-cholesterol levels were compared across the full low-density lipoprotein-cholesterol range. The prevalence of FH was estimated using the Dutch Lipid Clinic Network criteria, once using observed pre-treatment low-density lipoprotein-cholesterol and once using imputed pre-treatment low-density lipoprotein-cholesterol by following the common strategy of applying fixed correction factors to on-treatment low-density lipoprotein-cholesterol. Inter-individual variation in the low-density lipoprotein-cholesterol response to a fixed statin and dose was considerable, with a strong inverse relation of percentage reductions to pre-treatment low-density lipoprotein-cholesterol. The percentage low-density lipoprotein-cholesterol response was markedly lower at the left end of the pre-treatment low-density lipoprotein-cholesterol range especially for levels less than 3 mmol/L. The estimated prevalence of familial hypercholesterolaemia was 2% if using observed pre-treatment low-density lipoprotein-cholesterol and 10% when using imputed low-density lipoprotein-cholesterol. The inter-individual variation in the percentage low-density lipoprotein-cholesterol response to a given dose of a statin is largely dependent on the pre-treatment level: the lower the pre-treatment low-density lipoprotein-cholesterol level the smaller the percentage low-density lipoprotein-cholesterol reduction. The use of uniform correction factors to estimate pre-treatment low-density lipoprotein-cholesterol is not justified.

Justice, Care, and Gender: The Kohlberg-Gilligan Debate Revisited

In 1958, G. E. M. Anscombe wrote, "It is not profitable for us at present to do moral philosophy; that should be laid aside at any rate until we have an adequate philosophy of psychology, in which we are conspicuously lacking" (p. 186). Anscombe hinted (and she and many others pursued the hint) that the Aristotelian tradition was the best place to look for a richer and less shadowy conception of moral agency than either utilitarianism or Kantianism had provided. In the same year Anscombe published "Modern Moral Philosophy," Lawrence Kohlberg completed his dissertation at the University of Chicago, a dissertation that laid the foundations for what has been the dominant program in moral psychology for the last twenty-odd years. The contrast between the sort of Aristotelian philosophical psychology Anscombe envisaged and Kohlberg's program could not have been starker. Anscombe recommended that the concepts of "moral obligation and moral duty ... and of what is morally right and wrong, and of the moral sense of 'ought,' ought to be jettisoned ... because they are survivors ... from an earlier conception of ethics which no longer survives, and are only harmful without it" (p. 186). Kohlberg meanwhile claimed that people at the highest stage of moral development "answer [moral dilemmas] in moral words such as duty or morally right and use them in a way implying universality, ideals and impersonality" (1981, p. 22). And while Anscombe pointed to Aristotle as the possibility proof that ethics could be done with a more robust and realistic conception of moral agency than the will-o'-the-wisp Enlightenment conception which Iris Murdoch describes as "thin as a needle" (1970, p. 53) and Alasdair MacIntyre depicts as "ghostlike" (1982), Kohlberg derided Aristotelianism, calling it the "bag of virtues" model; and he explicitly rejected the view that personality is divided up "into cognitive abilities, passions or motives, and traits of