Cardiovascular Risk Management Guidelines Research Articles

Cardiovascular Risk Management in Persons with Dementia.

The number of people living with dementia, such as Alzheimer's disease, is increasing worldwide. Persons with dementia often have a high risk of atherosclerotic cardiovascular disease and they are therefore theoretically eligible for treatment of hypertension and hyperlipidemia. However, in this population, beneficial and harmful effects of cardiovascular risk management (CVRM) may be different compared to older persons without cognitive impairment. Current CVRM guidelines are based on trials from which persons with dementia were excluded. In this narrative review, we will discuss how current guidelines can be translated to persons with dementia and which aspects should be taken into account when treating hypertension and hyperlipidemia to prevent major adverse cardiovascular events (MACE). Survival time is significantly shorter in persons with dementia. We therefore suggest that since the main goal of CVRM is prevention of MACE, first of all, the patient's life expectancy and treatment wishes should be evaluated. Risk assessment tools are to be used with care, as they tend to overestimate the 5- and 10-year risk of MACE and benefit from CVRM in the prevention of MACE in persons with dementia. When the clinician and patient have decided that treatment is initiated or intensified, patients should be closely monitored since they are at high risk for adverse drugs events and overtreatment due to the natural course of blood pressure in persons with dementia. In the event of intolerance or side effects, medication should be switched or withdrawn. For persons with dementia and limited life expectancy, deprescribing should be part of usual care.

The role of cardiovascular risk assessment in addressing prevention of cardiovascular disease and cardiovascular complications of diabetes in South Asia

In the face of the rising incidence of cardiovascular diseases (CVD) and diabetes in low-income and middle-income countries in South Asia, the most cost-effective and equitable strategies for prevention of heart attacks, strokes and vascular complications of diabetes need to be incorporated into primary care services. Health system and resource limitations in these countries call for directing preventive services and pharmacological treatment to people with high cardiovascular risk, identified by risk stratification using hypertension and diabetes as entry points. Absolute cardiovascular risk prediction scores should be used routinely in primary care. Individual management guidelines for hypertension, dyslipidemia and diabetes need to be replaced by integrated and simplified cardiovascular risk management guidelines.

Blood pressure and cholesterol measurements in primary care: cross-sectional analyses in a dynamic cohort

BackgroundGuidelines on cardiovascular risk management (CVRM) recommend blood pressure (BP) and cholesterol measurements every 5 years in men aged ≥40 years and (post-menopausal) women aged ≥50 years.AimTo evaluate CVRM guideline implementation.Design & settingCross-sectional analyses in a dynamic cohort using primary care electronic health record (EHR) data from the Julius General Practitioners’ Network (JGPN) (n = 388 929).MethodTrends (2008–2018) were assessed in the proportion of patients with at least one measurement (BP and cholesterol) every 1, 2, and 5 years, in those with:1. a history of cardiovascular disease (CVD) and diabetes mellitus (DM);2. a history of DM only;3. a history of CVD only;4. a cardiovascular risk assessment (CRA) indication based on other medical history, or;5. no CRA indication.Trends were evaluated over time using logistic regression mixed-model analyses.ResultsTrends in annual BP and cholesterol measurement increased for patients with a history of CVD from 37.0% to 48.4% (P<0.001) and 25.8% to 40.2% (P<0.001). In the 5-year window from 2014–2018, BP and cholesterol measurements were performed respectively in 78.5% and 74.1% of all men aged ≥40 years and 82.2% and 78.5% of all women aged ≥50 years. Least measured were patients without a CRA indication (men 60.2% and 62.4%; women 55.5% and 59.3%).ConclusionThe fairly high frequency of CVRM measurements available in the EHR of patients in primary care suggests an adequate implementation of the CVRM guideline. As nearly all individuals visit the GP at least once within a 5-year time window, improvement of CVRM remains possible, especially in those without a CRA indication.

Feminizing Hormone Therapy Prescription Patterns and Cardiovascular Risk Factors in Aging Transgender Individuals in Australia.

ContextThe safety and efficacy of feminizing hormone therapy in aging transgender (trans) individuals is unclear. Current recommendations suggest transdermal estradiol beyond the age of 45 years, especially if cardiometabolic risk factors are present.ObjectiveTo evaluate feminizing hormone therapy regimens and cardiovascular risk factors in aging trans individuals.DesignRetrospective cross-sectional analysis.SettingPrimary care and endocrine specialist clinic in Melbourne, Australia.ParticipantsTrans individuals on feminizing therapy for ≥6 months.Main Outcomes MeasuresFeminizing hormone regimens and serum estradiol concentrations by age group: (a) ≥45 years, (b) <45 years, and prevalence of cardiometabolic risk factors in individuals ≥45 years.Results296 individuals were stratified by age group: ≥45 years (n=55) and <45 years (n=241). There was no difference in median estradiol concentration between groups (328 nmol/L vs. 300 nmol/L, p=0.22). However, there was a higher proportion of individuals ≥45 years treated with transdermal estradiol (31% vs. 8%, p<0.00001). Of those treated with oral estradiol, the median dose was lower in the ≥45 years group (4mg vs. 6mg, p=0.01). The most prevalent cardiometabolic risk factor in the ≥45 years group was hypertension (29%), followed by current smoking (24%), obesity (20%), dyslipidaemia (16%) and diabetes (9%).ConclusionsA greater proportion of trans individuals ≥45 years of age were treated with transdermal estradiol. Of those who received oral estradiol, the median dose was lower. This is important given the high prevalence of cardiometabolic risk factors in this age group, however cardiovascular risk management guidelines in this demographic are lacking.

The impact of the new Dutch guideline on cardiovascular risk management in patients with COPD: a retrospective study.

BackgroundPatients with chronic obstructive pulmonary disease (COPD) have an independent increased risk of cardiovascular (CV) disease. Cardiovascular risk (CVR) assessment should be offered to all patients with COPD, according to the new Dutch CVR management (CVRM) guideline (May 2019).AimTo evaluate the impact of the new CVRM guideline on the care of patients with COPD in primary care.Design & settingA retrospective study took place within five primary healthcare centres located in The Netherlands.MethodIn accordance with the guideline, the CVR of all patients with COPD was estimated and categorised. Data from 2014–2019 were used for the qualitative risk assessment based on comorbidities, and the quantitative Systematic Coronary Risk Evaluation (SCORE). In addition, the guideline-based follow-up was investigated.ResultsOf the 391 patients with COPD, 84.1% (n = 329) had complete data on CVR assessment: 90.3% (n = 297) had a (very) high risk, and 9.7% (n = 32) a low-to-moderate risk. Of the patients with (very) high risk, 73.4% (n = 218) received guideline-based follow-up (primary care: 95.4%, secondary care: 4.6%). In 15.9% (n = 62) of all patients with COPD, the CVR profile was not measured and of the (very) high-risk patients, 26.6% (n = 79) were not enroled in a CV care programme.ConclusionWhereas in the majority of patients with COPD the CVR is already known, for one out of six patients this CVR still has to be assessed according to the recently updated guideline. Moreover, once a (very) high risk has been assessed, as a consequence CV treatment of risk factors should be intensified in one out of four patients with COPD. Adherence to the new CVRM guideline could provide improvement in CVRM in more than a third of all patients with COPD.

The Impact of the 2019 European Guideline for Cardiovascular Risk Management: A Cross-Sectional Study in General Practice.

The aim of this study was to assess the impact of the 2019 published European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) guideline on cardiovascular (CV) risk management compared with its predecessor from 2016 in a cohort in general practice. We performed a cross-sectional retrospective study with data from electronic medical records. The study cohort included 103,351 patients with known CV risk. We assessed changes in CV risk classification and low-density lipoprotein cholesterol (LDL-C) target values, the impact on LDL-C achievement rates, and the current lipid-lowering treatments. Under the 2019 ESC guideline, CV risk categories changed in 27.5% of patients, LDL-C target levels decreased in 71.4% of patients, and LDL-C target achievement rate dropped from 31.1% to 16.5%. Among non-achievers according to the 2019 guideline, 52.2% lacked lipid-lowering drugs entirely, and 41.5% had conventional drugs at a submaximal intensity. Of patients in the high-risk and very high-risk categories, at least 5% failed to achieve the LDL-C target level despite treatment at maximal intensity with conventional lipid-lowering drugs, making them eligible for PCSK-9 inhibitors. In conclusion, the 2019 ESC/EAS guideline lowered LDL-C target values for the majority of patients in general practice and halved LDL-C target achievement rates. There is still a large undeveloped potential to lower CV risk by introducing conventional lipid-lowering drugs, particularly in patients at high or very high CV risk. A substantial proportion of the patients can only achieve their LDL-C targets using PCSK-9 inhibitors, which would currently require an at least 10-fold increase in prescribing of these drugs.

Acomputerised decision support system for cardiovascular risk management 'live' in the electronic health record environment: development, validation and implementation-the Utrecht Cardiovascular Cohort Initiative.

PurposeWe set out to develop a real-time computerised decision support system (CDSS) embedded in the electronic health record (EHR) with information on risk factors, estimated risk, and guideline-based advice on treatment strategy in order to improve adherence to cardiovascular risk management (CVRM) guidelines with the ultimate aim of improving patient healthcare.MethodsWe defined a project plan including the scope and requirements, infrastructure and interface, data quality and study population, validation and evaluation of the CDSS.ResultsIn collaboration with clinicians, data scientists, epidemiologists, ICT architects, and user experience and interface designers we developed a CDSS that provides ‘live’ information on CVRM within the environment of the EHR. The CDSS provides information on cardiovascular risk factors (age, sex, medical and family history, smoking, blood pressure, lipids, kidney function, and glucose intolerance measurements), estimated 10-year cardiovascular risk, guideline-compliant suggestions for both pharmacological and non-pharmacological treatment to optimise risk factors, and an estimate on the change in 10-year risk of cardiovascular disease if treatment goals are adhered to. Our pilot study identified a number of issues that needed to be addressed, such as missing data, rules and regulations, privacy, and patient participation.ConclusionDevelopment of a CDSS is complex and requires a multidisciplinary approach. We identified opportunities and challenges in our project developing a CDSS aimed at improving adherence to CVRM guidelines. The regulatory environment, including guidance on scientific evaluation, legislation, and privacy issues needs to evolve within this emerging field of eHealth.

Hypertension Editors' Picks Preeclampsia.

Hypertension Editors' Picks Preeclampsia.

Prescription patterns of lipid lowering agents among older patients in general practice: an analysis from a national database in the Netherlands.

Dutch cardiovascular risk management guidelines state almost every older adult (≥70 years) is eligible for a lipid lowering drug (LLD). However, life expectancy, frailty or comorbidities may influence this treatment decision. investigate how many older adults, according to age, frailty (Drubbel-frailty index) and comorbidities were prescribed LLDs. data of 244,328 adults ≥70 years from electronic health records of 415 Dutch general practices from 2011-15 were used. Number of LLD prescriptions in patients with (n = 55,309) and without (n = 189,019) cardiovascular disease (CVD) was evaluated according to age, frailty and comorbidities. about 69% of adults ≥70 years with CVD and 36% without CVD were prescribed a LLD. LLD prescriptions decreased with age; with CVD: 78% aged 70-74 years and 29% aged ≥90 years were prescribed a LLD, without CVD: 37% aged 70-74 years and 12% aged ≥90 years. In patients with CVD and within each age group, percentage of LLD prescriptions was 20% point(pp) higher in frail compared with non-frail. In patients without CVD, percentage of LLD prescriptions in frail patients was 11pp higher in adults aged 70-74 years and 40pp higher in adults aged ≥90 years compared to non-frail. Similar trends were seen in the analyses with number of comorbidities. in an older population, LLD prescriptions decreased with age but-contrary to our expectations-LLD prescriptions increased with higher frailty levels.

Clinical Implications

Clinical Implications

Trajectory of Cardiovascular Risk Factors After Hypertensive Disorders of Pregnancy.

Women with a history of a hypertensive disorder of pregnancy (HDP) are at increased risk of premature cardiovascular disease. Cardiovascular risk management guidelines emphasize the need for prevention of cardiovascular disease in these women but fail to provide uniform recommendations on when and how to start cardiovascular risk assessment. The aim of this study was to identify a window of opportunity in which to start cardiovascular risk factor assessment by investigating changes in blood pressure, lipids, and fasting glucose levels over time in women with a history of an HDP. We identified women with a history of a normotensive pregnancy (n=1811) or an HDP (n=1005) within a high-risk population-based cohort study. We assessed changes in blood pressure, lipids, glucose, 10-year cardiovascular risk and the occurrence of hypertension, dyslipidemia, and diabetes mellitus longitudinally using 5 measurements at 3-year intervals. Generalized estimating equations were used for statistical analysis, with age as the time variable, adjusting for multiple comparisons using the least significant differences method. In women with an HDP, the overall prevalence of hypertension ( P<0.0001), dyslipidemia ( P=0.003), and diabetes mellitus ( P<0.0001) was significantly higher. They also developed hypertension and diabetes mellitus earlier. At age 35, few women with HDP need to be screened to detect clinically relevant hypertension: 9 need to be screened to detect 1 woman with a treatment indication as opposed to 38 women with history of a normotensive pregnancy. Our data supports cardiovascular follow-up of women with a history of an HDP starting within the fourth decade of life.

Cardiovascular risk management after reproductive and pregnancy-related disorders: A Dutch multidisciplinary evidence-based guideline.

In the past decades evidence has accumulated that women with reproductive and pregnancy-related disorders are at increased risk of developing cardiovascular disease (CVD) in the future. Up to now there is no standardised follow-up of these women becausee guidelines on cardiovascular risk management for this group are lacking. However, early identification of high-risk populations followed by prevention and treatment of CVD risk factors has the potential to reduce CVD incidence. Therefore, the Dutch Society of Obstetrics and Gynaecology initiated a multidisciplinary working group to develop a guideline for cardiovascular risk management after reproductive and pregnancy-related disorders. The guideline addresses the cardiovascular risk consequences of gestational hypertension, preeclampsia, preterm delivery, small-for-gestational-age infant, recurrent miscarriage, polycystic ovary syndrome and premature ovarian insufficiency. The best available evidence on these topics was captured by systematic review. Recommendations for clinical practice were formulated based on the evidence and consensus of expert opinion. The Dutch societies of gynaecologists, cardiologists, vascular internists, radiologists and general practitioners reviewed the guideline to ensure support for implementation in clinical practice. For all reproductive and pregnancy-related disorders a moderate increased relative risk was found for overall CVD, except for preeclampsia (relative risk 2.15, 95% confidence interval 1.76-2.61). Based on the current available evidence, follow-up is only recommended for women with a history of preeclampsia. For all reproductive and pregnancy-related disorders optimisation of modifiable cardiovascular risk factors is recommended to reduce the risk of future CVD.

Marked underdiagnosis and undertreatment of hypertension and hypercholesterolaemia in rheumatoid arthritis.

To investigate the prevalence of underdiagnosis and undertreatment of traditional cardiovascular risk factors in RA patients. RA patients ⩽70 years of age without cardiovascular disease (CVD) or diabetes mellitus were included. Systolic blood pressure and a fasting lipid profile were measured. The 10-year CVD risk was estimated using the Dutch Cardiovascular Risk Management (CVRM) guideline and EULAR modifications of the Systemic Coronary Risk Evaluation tables. A total of 327 patients were included (female gender: 68%). The mean age was 53 (11) years [mean (s.d.)]. The median disease duration was 7 years (inter quartile range: 2-14 years). According to the CVRM guideline, 52% of the patients had a CVD risk ⩾20% and according to the EULAR guidelines, 18% of the patients had a CVD risk ≥ 20%. Low-density lipoprotein cholesterol (LDL-C) >2.5 mmol/l was found in >80% of the patients with a CVD risk ⩾10% as estimated by both the CVRM and EULAR guidelines, and 32-42% of the patients with a CVD risk ⩾10% had a systolic blood pressure >140 mmHg, depending on the risk model used. Statins were used in 6% and antihypertensives in 23-25%, and 50-86% of these patients did not reach the recommended treatment targets. Regardless of the adapted risk assessment model used, untreated hypertension and hypercholesterolaemia were frequently found in RA patients with increased CVD risk. Treatment of these cardiovascular risk factors deserves more attention in RA. The Dutch Trial Register, www.trialregister.nl, NTR3873.

Implementation of Out-of-Office Blood Pressure Monitoring in the Netherlands: From Clinical Guidelines to Patients' Adoption of Innovation.

Out-of-office blood pressure monitoring is promoted by various clinical guidelines toward properly diagnosing and effectively managing hypertension and engaging the patient in their care process. In the Netherlands, however, the Dutch cardiovascular risk management (CVRM) guidelines do not explicitly prescribe 24-hour ambulatory blood pressure measurement (ABPM) and home BP measurement (HBPM). The aim of this descriptive study was to develop an understanding of patients’ and physicians’ acceptance and use of out-of-office BP monitoring in the Netherlands given the CVRM recommendations.Three small focus group discussions (FGDs) with patients and 1 FGD with physicians were conducted to explore the mechanisms behind the acceptance and use of out-of-office BP monitoring and reveal real-world challenges that limit the implementation of out-of-office BP monitoring methods. To facilitate the FGDs, an analytical framework based on the technology acceptance model (TAM), the theory of planned behavior and the model of personal computing utilization was developed to guide the FGDs and analysis of the transcriptions of each FGD.ABPM was the out-of-office BP monitoring method prescribed by physicians and used by patients. HBPM was not offered to patients even with patients’ feedback of poor tolerance of ABPM. Even as there was little awareness about HBPM among patients, there were a few patients who owned and used sphygmomanometers. Patients professed and seemed to exhibit self-efficacy, whereas physicians had reservations about (all of their) patients’ self-efficacy in properly using ABPM. Since negative experience with ABPM impacted patients’ acceptance of ABPM, the interaction of factors that determined acceptance and use was found to be dynamic among patients but not for physicians.In reference to the CVRM guidelines, physicians implemented out-of-office BP monitoring but showed a strong preference for ABPM even where there is poor tolerance of the method. We found that physicians’ positive attitude to ABPM enabled the use of the method by patients which, in turn, impeded the diffusion of HBPM. For patients, the acceptance process of HBPM can only begin after the physician has adopted the innovation. Physicians are in a position to encourage as well as hinder out-of-office BP monitoring and self-management.

Le risque cardiovasculaire dans la spondyloarthrite axiale

An increased cardiovascular risk has been consistently reported in inflammatory rheumatic diseases. An important number of studies found the same higher cardiovascular risk in rheumatoid arthritis and systemic lupus erythematosus. On the contrary, the presence of this increase cardiac risk is less documented in ankylosing spondylitis (AS) with some contradictory information in the studies. This review aims to report the current data in 2014 on the high cardiovascular risk in AS, the prevalence of cardiovascular risk factors in this rheumatic disease, the cardiovascular effects of treatment and the guidelines for cardiovascular risk management.

O119. Cardiovascular risk management after reproductive and pregnancy related disorders: A Dutch multidisciplinary evidence-based guideline

Introduction In the past decades evidence has accumulated that women with reproductive and pregnancy related disorders are at increased risk of developing cardiovascular disease (CVD) in the future. Up to now there is no standardized follow-up of these women since guidelines on cardiovascular risk management for this group are lacking. However, early identification of high-risk populations followed by prevention and treatment of CVD risk factors has the potential to reduce CVD incidence. Objective The Dutch Society of Obstetrics and Gynaecology initiated a multidisciplinary working group (gynecologists, cardiologist, vascular internist, radiologist, general practitioner, epidemiologist and representatives of patient associations) to develop a guideline for cardiovascular risk management after reproductive and pregnancy related disorders. Methods The guideline was developed using the “Appraisal of Guidelines for Research and Evaluation” instrument. The guideline addresses the cardiovascular risk consequences of gestational hypertension, preeclampsia, preterm delivery, small-for-gestational-age infant, recurrent miscarriage, polycystic ovary syndrome and premature ovarian insufficiency. The best available evidence on these topics was gathered by systematic review and the relation between the reproductive or pregnancy related disorders and CVD risk and risk factors was assessed by meta-analysis. Recommendations for clinical practice were formulated based on the number and quality of the studies and presence or absence of a relative risk > 2 of developing CVD events and/or risk factors from the meta-analysis. The Dutch societies of gynaecologists, cardiologists, vascular internists, radiologists, and general practitioners endorsed the guideline to ensure support for implementation in clinical practice. Results For all reproductive and pregnancy related disorders only a moderate increased relative risk ( 2) was found for overall CVD, except for preeclampsia (relative risk 2.15, 95% CI 1.76–2.61). Based on the current available evidence, follow-up is only recommended for women with a history of preeclampsia. A cardiovascular risk profile should be offered at the age of 50 years. Assessment of CVD risk and treatment of cardiovascular risk factors should be performed according to the Dutch guideline for cardiovascular risk management. For all reproductive and pregnancy related disorders optimization of modifiable cardiovascular risk factors is recommended to reduce the risk of future CVD. Conclusion In this guideline we present the recommendations for cardiovascular risk management after reproductive and pregnancy related disorders. To the best of our knowledge we are the first to make such recommendations in a national guideline.

Can and should carotid ultrasound be used in cardiovascular risk assessment?: The internist's perspective

Cardiovascular risk management is a major and challenging task for internists. Risk scores using algorithms based on traditional risk factors are helpful in identifying patients in whom intensive prevention strategies are warranted. However there remains a need for more accurate screening tools to allow clinicians to individualize the primary prevention programs to their patients.Approximately 40–80% of apparently healthy, asymptomatic subjects exhibit increased thickness of the lamina intima-media of the carotid artery or have atherosclerotic carotid plaques. These abnormalities can be measured safely and at low cost by ultrasound. Subclinical carotid lesions are strongly associated with generalized atherosclerotic burden and the risk of future cardiovascular events. Although many cardiovascular risk management guidelines recommend the use of these parameters incorporation in clinical practice is still not commonplace.Based on the current literature it can be stated that in high risk patients there is no additional value of carotid ultrasound because even in the absence of carotid lesions these patients should receive an intensive risk reduction regime. In the large low-intermediate risk group however carotid ultrasound findings carry subtle but possibly clinically relevant information about cardiovascular risk profile. The effect of treatment decisions based on carotid ultrasound parameters has not been studied. Sequential measurements to monitor progression and evaluate treatment response on an individual basis are not sufficiently reproducible.We therefore recommend the use of carotid ultrasound in low to intermediate risk patients but emphasize the importance of interpreting the results in conjunction with all cardiovascular risk factors and avoid follow-up measurements.

Application of the European Society of Cardiology, Adult Treatment Panel III and American College of Cardiology/American Heart Association guidelines for cardiovascular risk management in a French cohort of rheumatoid arthritis

BackgroundPatients with rheumatoid arthritis (RA) have greater rates of cardiovascular mortality and RA is an independent cardiovascular risk factor. For the management of cholesterol, the American College of Cardiology/American Heart Association (ACC/AHA) developed new guidelines for the general population. None of the European or American guidelines are specific to RA. The European League Against Rheumatism (EULAR) recommends applying a coefficient to cardiovascular risk equations based on the characteristics of RA. Our objective was to compare the three different sets of guidelines for the eligibility of statin therapy in RA-specific population with very high risk of cardiovascular disease. Methods and resultsWe calculated the proportion of patients eligible for statins according to the guidelines of the European Society of Cardiology (ESC), the Adult Treatment Panel III (ATP-III) and the ACC/AHA in a French cohort of statin-naïve RA patients at least 40years age. Of the 547 women and 130 men analyzed, statins would be recommended for 9.1% of the women and 26.4% of the men, 15.6% of the women and 53.1% of the men, 38.8% of the women and 78.5% of the men, according to the ESC, ATP-III and ACC/AHA guidelines respectively. ConclusionsIn RA patients, as has been observed in the general population, discordance in risk assessment and cholesterol treatment was observed between the three sets of guidelines. The use of the new ACC/AHA guidelines would expand the eligibility for statins and may be applied to RA population a condition at very high risk of cardiovascular disease.

Guideline treatment results in regression of atherosclerosis in type 2 diabetes mellitus.

Efficacy of guideline cardiovascular disease prevention regimens may differ between patients with or without type II diabetes mellitus. We therefore compared change in carotid artery wall dimensions in type II diabetes mellitus and non-type II diabetes mellitus patients with a history of a major cardiovascular disease event, using magnetic resonance imaging. Thirty type II diabetes mellitus patients and 29 age- and sex-matched non-diabetes mellitus patients with a history of stroke or myocardial infarction and a carotid artery stenosis (15%-70%) were included. In all patients, treatment was according to cardiovascular risk management guidelines. At baseline and follow-up, carotid artery vessel wall dimensions were measured using 1.5 T magnetic resonance imaging. After 2 years of follow-up, total wall volume of the carotid artery in type II diabetes mellitus patients decreased by 9.6% (p = 0.016). In contrast, stabilization rather than regression of carotid artery wall dimensions was observed in non-diabetes mellitus patients over a 2-year period. Body mass index was identified as a predictor of total wall volume decrease. Guideline treatment arrests atherogenesis in non-diabetes mellitus patients and even decreases vessel wall dimensions in type II diabetes mellitus patients. Baseline body mass index predicts cardiovascular disease prevention efficacy expressed as decrease in total wall volume. These data emphasize the importance of optimal cardiovascular-prevention, particularly in diabetes patients with a high body mass index.

Supporting health care professionals to improve the processes of shared decision making and self-management in a web-based intervention: randomized controlled trial.

BackgroundResearch to assess the effect of interventions to improve the processes of shared decision making and self-management directed at health care professionals is limited. Using the protocol of Intervention Mapping, a Web-based intervention directed at health care professionals was developed to complement and optimize health services in patient-centered care.ObjectiveThe objective of the Web-based intervention was to increase health care professionals’ intention and encouraging behavior toward patient self-management, following cardiovascular risk management guidelines.MethodsA randomized controlled trial was used to assess the effect of a theory-based intervention, using a pre-test and post-test design. The intervention website consisted of a module to help improve professionals’ behavior, a module to increase patients’ intention and risk-reduction behavior toward cardiovascular risk, and a parallel module with a support system for the health care professionals. Health care professionals (n=69) were recruited online and randomly allocated to the intervention group (n=26) or (waiting list) control group (n=43), and invited their patients to participate. The outcome was improved professional behavior toward health education, and was self-assessed through questionnaires based on the Theory of Planned Behavior. Social-cognitive determinants, intention and behavior were measured pre-intervention and at 1-year follow-up.ResultsThe module to improve professionals’ behavior was used by 45% (19/42) of the health care professionals in the intervention group. The module to support the health professional in encouraging behavior toward patients was used by 48% (20/42). The module to improve patients’ risk-reduction behavior was provided to 44% (24/54) of patients. In 1 of every 5 patients, the guideline for cardiovascular risk management was used. The Web-based intervention was poorly used. In the intervention group, no differences in social-cognitive determinants, intention and behavior were found for health care professionals, compared with the control group. We narrowed the intervention group and no significant differences were found in intention and behavior, except for barriers. Results showed a significant overall difference in barriers between the intervention and the control group (F 1=4.128, P=.02).ConclusionsThe intervention was used by less than half of the participants and did not improve health care professionals’ and patients’ cardiovascular risk-reduction behavior. The website was not used intensively because of time and organizational constraints. Professionals in the intervention group experienced higher levels of barriers to encouraging patients, than professionals in the control group. No improvements were detected in the processes of shared decision making and patient self-management. Although participant education level was relatively high and the intervention was pre-tested, it is possible that the way the information was presented could be the reason for low participation and high dropout. Further research embedded in professionals’ regular consultations with patients is required with specific emphasis on the processes of dissemination and implementation of innovations in patient-centered care.Trial RegistrationNetherlands Trial Register Number (NTR): NTR2584; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2584 (Archived by WebCite at http://www.webcitation.org/6STirC66r).