Management Of Disease Risk Factors Research Articles

Abstract 4138220: Traditional and HIV-specific Risk Factors Are Associated with Incident Non-valvular Atrial Fibrillation and Atrial Flutter among Underrepresented Racial and Ethnic Minority Groups Living with HIV

Introduction: With effective antiretroviral therapy (ART), HIV can now be managed as a chronic disease. Chronic disease and cardiovascular risk factor management is especially important for underrepresented racial and ethnic minority groups (UREG). Non-valvular atrial fibrillation and atrial flutter (NVAF) have not been adequately studied in UREG with HIV. Research Questions: Among UREG with HIV, what is the incidence of NVAF? What factors are associated with incident NVAF? Aims: To narrow an evidence gap among UREG with HIV by 1) describing the incidence of NVAF and 2) identifying factors associated with incident NVAF. Methods: This is an ancillary study of the Pathways to Cardiovascular Disease Prevention and Impact of Specialty Referral in Underrepresented Racial and Ethnic Minorities with HIV (PATHWAYS) study, a retrospective population-based study of HIV care patterns among UREG with HIV. Patients without a known history of NVAF entered our study cohort at the date of their first documented HIV diagnosis. We computed the cumulative incidence of NVAF over five years of follow-up (mean 3.4, SD 1.6), handling death as a competing risk. Cox regression analysis was used to examine the univariate associations between characteristics at HIV diagnosis and incident NVAF, adjusting for site and date of HIV diagnosis. Results: From 2015-2019, 10,945 UREG meeting entry criteria were identified. On average, patients were 67.1% male, 94.4% Black, and 8.5% Hispanic. Average CHA2DS2VASc score was 0.92 (SD 1.1) and 63.4% were on ART. Cumulative incidence of NVAF at one and five years after HIV diagnosis were 0.48% (95% CI 0.36-0.63) and 2.16% (95% CI 1.85-2.51), respectively. HIV-related factors associated with incident NVAF included baseline CD4 count <200 (HR 1.84, 95% CI 1.20-2.80) and initial ART including protease inhibitors (HR 1.56, 95% CI 1.14-2.13) and/or integrase strand transfer inhibitors (HR 1.47, 95% CI 1.08-1.99). Additional associated factors included older age, Medicare, cardiology visit(s) in prior year, and co-morbid diseases including hypertension, hyperlipidemia, coronary and peripheral artery disease, prior stroke/transient ischemic attack, heart failure, and chronic kidney disease. Conclusions: In a large cohort of UREG living with HIV, both traditional and HIV-specific risk factors are associated with increased risk of incident NVAF. Interventions to mitigate NVAF risk in this population will require interdisciplinary, team-based approaches.

Cardiovascular disease burden and risk factor management in cancer survivors: insights from a large-scale East London cohort

Abstract Introduction Improvements in cancer survival have led to an urgent need to address long-term health issues among survivors, notably increased risk of cardiovascular disease (CVD). Shared risk factors may underpin at least part of this excess risk. Aims To investigate differences in cardiovascular risk profile between cancer survivors and controls; and to assesses the management of hypertension and statin use among cancer survivors compared with controls in a multi-ethnic and socio-economically diverse population. Methods The data were obtained from electronic health records of 1.2 million people registered with general practices in East London. It provides a snapshot of health records at the time of data extraction (01/01/2023). We identify individuals with record of past cancer (grouped into 20 cancer types) and their cardiovascular profile. Each cancer-exposed patient was age- and sex-matched to four non-cancer comparators. Multivariable logistic regression, with extensive adjustment for demographic and health-related variables, was used to elucidate the independent associations of past cancer with a range of cardiovascular outcomes. Patterns of guideline-directed risk factor control among cancer patients with hypertension and ischaemic CVDs (vs non-cancer controls) were assessed. Results The study consisted of 18,839 cancer survivors and 75,356 matched controls (64±15 years, 43% male), with marked ethnic diversity (cancer survivors: 48% White, 24% Black and 22% Asian) and socio-economic deprivation. Compared to matched controls, patients with past cancer had a higher prevalence of hypertension (44% vs. 41%) and chronic kidney disease (18% vs. 14%). We observed a higher prevalence of CVDs including venous thromboembolism (VTE) (5.6% vs. 2.8%), atrial fibrillation (AF) (6.5% vs. 5%), and heart failure (HF) (4.4% vs. 3.4%) among cancer survivors. Regression models fully adjusted for shared risk factors demonstrated an increased risk of a range of CVDs in patients with (any) past cancer, including VTE (OR 2.01), HF (OR 1.31) and AF (OR 1.27). CVD risk varied across cancer types (Figure 1). For example, lung cancer survivors had an elevated risk of VTE (OR 4.02), AF (OR 2.47), IHD (OR 1.45) and peripheral artery disease (OR 1.67) while colorectal cancer survivors had increased risks of VTE (OR 2.68), HF (OR 1.4) and AF (OR 1.32). In subgroup analyses, control of blood pressure and cholesterol did not differ significantly across cancer survivors and matched controls with hypertension and ischaemic CVDs, respectively. Conclusion We show higher burden of VRFs and an increased risk of CVDs among cancer survivors compared with non-cancer controls, with notable variation across cancer types. The lack of difference in control of blood pressure and cholesterol between cancer survivors and controls suggests that these risk factors did not explain the increased risk. Suggesting that an individualised approach to risk management is likely to be warranted.Risk of CVDs in Cancer Survivors

Evaluating the World Health Organization's HEARTS Model for Hypertension and Diabetes Management: A Pilot Implementation Study in Guatemala.

The World Health Organization HEARTS Technical Package is a widely implemented global initiative to improve the primary care management of cardiovascular disease risk factors. The study's objective is to report outcomes from a pilot implementation trial of integrated hypertension and diabetes management based on the HEARTS model in Guatemala. We conducted a single-arm pilot implementation trial over 6 months from October 2023 to May 2024 in 11 Guatemalan Ministry of Health primary care facilities in two districts. The pilot evaluated a package of five HEARTS-aligned implementation strategies to improve the pharmacological treatment of hypertension and diabetes. The primary outcomes were feasibility and acceptability, measured through 20 structured interviews with Ministry of Health employees and by examining enrollment and retention. Secondary outcomes included a suite of implementation and clinical outcomes, including treatment rate. The study enrolled 964 patients, of whom 58.8% had hypertension only, 30.4% had diabetes only, and 10.8% had both conditions. Surveys on feasibility and acceptability among Ministry of Health staff had a median score of 5.0 (IQR: 5.0 to 5.0) and 5.0 (IQR range: 4.8 to 5.0), respectively, exceeding the prespecified benchmark of ≥3.5. Both districts achieved the prespecified benchmark of enrolling ≥25 hypertension patients and ≥25 diabetes patients. Only 36% of patients attended a follow-up visit within three months, lower than the prespecified benchmark of ≥75%. M treatment rates during the pilot increased by 22.3 (95% CI: 16.2 to 28.4; P<0.001) and 3.5 (95% CI: -1.6 to 8.7; P=0.17) patients per month for hypertension and diabetes, respectively. Implementation of an integrated hypertension and diabetes model based on HEARTS was generally feasible and acceptable in the Ministry of Health in Guatemala. Findings can refine national scale-up in Guatemala and inform HEARTS implementation projects in other settings.

Abstract 15793: Impact of Cardiac Rehabilitation on Cardiovascular Disease Risk Factor Management at 1 and 3 Year Follow-Up

Introduction: Cardiac rehabilitation (CR) is a cornerstone of secondary prevention for cardiovascular disease (CVD). CR participation is associated with improvements in secondary CVD risk factor management. However, it is unclear if CR participation is associated with maintained improvements in CVD risk factor management following CR completion. Purpose: The aim of this study was to assess the impact of CR participation on CVD risk factor management at 1 and 3 years following CR completion. Methods: This retrospective study analyzed 911 patients (73% male) enrolled in the CR program at Mayo Clinic from 2013 to 2020. Patient demographics, clinical characteristics, and CVD risk factor management were examined pre and post CR as part of clinical practice and assessed passively at 1 and 3 years following CR. Secondary prevention CVD risk factor goals included total cholesterol (&lt;200 mg/dL), HDL cholesterol (&gt;40 mg/dL), LDL cholesterol (&lt;100 mg/dL), triglycerides (&lt;150 mg/dL), systolic and diastolic blood pressure (&lt;130 and &lt;80 mmHg), and body mass index (BMI) (18.5-24.9 kg/m 2 ). Results: The mean age was 66±12 years and on average 33±9 CR sessions were attended. Table 1 shows the percentage (%) of patients meeting the secondary prevention CVD risk factor goals. The % of patients meeting the goals for total cholesterol, LDL, triglycerides, and diastolic blood pressure were higher post than pre CR. There were no changes in the % of patients meeting the goals for total cholesterol or LDL at 1 and 3 year follow up compared to post CR. At 1 and 3 year follow up, there was a lower % of patients meeting the goals for systolic and diastolic blood pressure and triglycerides (at 1 year follow up only) than post CR. No changes were present in the % of patients meeting the goals for HDL and BMI at any timepoint (all, p&gt;0.09). Conclusions: CR participation was associated with maintained improvements in lipid management, but not in triglycerides or blood pressure control at 1 and 3 years following CR.

Impact of the COVID-19 pandemic on CVD prevention between different socioeconomic groups in Switzerland

BackgroundThe COVID-19 pandemic disrupted the continuing management of cardiovascular disease (CVD) risk factors in the population. Socioeconomic status (SES) is a major determinant of health. Whether the COVID-19 pandemic increased,...

Myocardial Work Evaluation—A Useful Non-Invasive Method to Predict Coronary Artery Sub-Occlusion in a Patient with Unstable Angina and Multiple Myocardial Revascularization Interventions

While lifestyle changes, management of coronary artery disease (CAD) risk factors, myocardial revascularization procedures, and medication can improve a patient's prognosis, de novo native coronary lesions and in-stent restenosis (ISR) remain significant clinical concerns. ISR is more frequent with a bare-metal stent than with a drug-eluting stent and has been documented in around 12% of DES patients. Acute coronary syndrome (ACS) manifests as unstable angina in about 30% to 60% of ISR patients. Myocardial work imaging is a modern, non-invasive technique able to identify individuals with critical coronary artery lesions with high sensitivity and specificity. We present the case of a 72-year-old Caucasian gentleman with multiple cardiovascular risk factors, admitted to the Cardiology Clinic of Timișoara Municipal Hospital with unstable angina. From 1999 to 2021, the patient experienced two myocardial infarctions, a double aortocoronary bypass graft, and multiple percutaneous coronary interventions with 11 stent implantations, including 6 for ISR. Using two-dimensional speckle-tracking echocardiography and myocardial work assessment, we detected that the lateral wall of the left ventricle had a severely impaired deformation pattern. Angio-coronarography was performed, and sub-occlusion of the posterolateral branch of the right coronary artery was found. Angioplasty was performed and a DES was inserted, with a good final angiographic result and complete release of symptoms. In patients with a history of multiple myocardial revascularization interventions and ISR, it is challenging to identify the critical ischemia region by non-invasive methods. Myocardial work imaging was beneficial in the detection of the altered deformation patterns indicating significant ischemia, its accuracy being superior to that of LV strain, as proven by coronary angiography. Urgent coronary angiography followed by angioplasty and stent implantation resolved the issue.

Cohort profile: the Utrecht Cardiovascular Cohort–Second Manifestations of Arterial Disease (UCC-SMART) Study–an ongoing prospective cohort study of patients at high cardiovascular risk in the Netherlands

PurposeThe Utrecht Cardiovascular Cohort–Second Manifestations of Arterial Disease (UCC-SMART) Study is an ongoing prospective single-centre cohort study with the aim to assess important determinants and the prognosis of cardiovascular disease...

Adoption of shared decision-making and clinical decision support for reducing cardiovascular disease risk in community health centers.

Electronic health record (EHR)-based shared decision-making (SDM) and clinical decision support (CDS) systems can improve cardiovascular disease (CVD) care quality and risk factor management. Use of the CV Wizard system showed a beneficial effect on high-risk community health center (CHC) patients' CVD risk within an effectiveness trial, but system adoption was low overall. We assessed which multi-level characteristics were associated with system use. Analyses included 80195 encounters with 17931 patients with high CVD risk and/or uncontrolled risk factors at 42 clinics in September 2018-March 2020. Data came from the CV Wizard repository and EHR data, and a survey of 44 clinic providers. Adjusted, mixed-effects multivariate Poisson regression analyses assessed factors associated with system use. We included clinic- and provider-level clustering as random effects to account for nested data. Likelihood of system use was significantly higher in encounters with patients with higher CVD risk and at longer encounters, and lower when providers were >10 minutes behind schedule, among other factors. Survey participants reported generally high satisfaction with the system but were less likely to use it when there were time constraints or when rooming staff did not print the system output for the provider. CHC providers prioritize using this system for patients with the greatest CVD risk, when time permits, and when rooming staff make the information readily available. CHCs' financial constraints create substantial challenges to addressing barriers to improved system use, with health equity implications. Research is needed on improving SDM and CDS adoption in CHCs. ClinicalTrials.gov, NCT03001713, https://clinicaltrials.gov/.

Increased end-stage renal disease risk in age-related macular degeneration: a nationwide cohort study with 10-year follow-up

Common etiologies between age-related macular degeneration (AMD) and kidney disease advocate a close link between AMD and end-stage renal disease (ESRD). However, the risk of ESRD in people with AMD was not reported. Here, we investigated the association between AMD and the risk of ESRD by using a nationwide, population-based cohort data in Korea. 4,206,862 participants aged 50 years or older were categorized by presence of AMD and visual disability. Risk of ESRD was the primary outcome. Cox regression hazard model was used to examine the hazard ratios (HRs) with adjustment for potential confounders. Stratified analyses by age, sex, baseline kidney function, and cardiometabolic comorbidities were performed. During the mean 9.95 years of follow-up, there were 21,759 incident ESRD events (0.52%). AMD was associated with 33% increased risk of ESRD (adjusted HR [aHR] 1.33, 95% confidence interval [CI] 1.24–1.44), and the risk was even higher when accompanied by visual disability (aHR 2.05, 95% CI 1.68–2.50) than when not (aHR 1.26, 95% CI 1.17–1.37). Age, baseline kidney function, and cardiometabolic comorbidities significantly interact between AMD and the risk of ESRD. Our findings have clinical implications on disease prevention and risk factor management of ESRD in patients with AMD.

Using Health in All Policies Approach for the Management of Non-Communicable Disease Risk Factors: A Developing Country Experience.

Background: Controlling and preventing non-communicable diseases and their risk factors through multisector collaboration and participation of other stakeholders requires structures that provide the necessary basis for sustainable interaction between stakeholders with legal support. The purpose of this study is to express the experience of the Islamic Republic of Iran in advancing the goals of the National Plan on Control and Prevention of Non-Communicable Diseases (NCD) through Health in All Policies (HiAP) approach and multisector collaboration. Methods: In this qualitative study, all documents related to the control and prevention of non-communicable diseases in the Secretariat of the Supreme Council for Health and Food Security(SCHFS) in the period 2013-2020 were reviewed. Data were thematically analyzed with the qualitative content analysis method; coding has done manually. Results: Multisector work group, which is one of work groups in the National Committee for control and prevention of NCD, applies its effect through SCHFS that proposed a four-level policy formulation and decision-making units for multisector collaboration based on political and administrative structure and HiAP approach at the national and provincial level. The Memorandum of Understanding (MOU) and health secretariats are used as tools for a multisector approach in non-communicable disease management. Conclusion: To draw up an appropriate structure for multisector collaboration for health, it is necessary to have a whole government-policy approach, through which all relevant organizations are appointed to engage and work together in a coherent framework since a sustainable framework based on shared trust and understanding for multisector decision-making and health action is a prerequisite for achieving health goals in NCD management.

Review on Toxicity of Antihypertensive Drugs

Adverse drug reactions are common and pose a serious health problem, limiting treatment options, causing compliance issues, and even leading to therapy discontinuation. Hypertension is a chronic disease that is regarded as a major risk factor for cardiovascular disease. To achieve a target blood pressure in an individual patient, a wide range of anti-hypertensive agents are available as single or combination therapy, whereas combination therapy increases the risk of developing Adverse Drug Reaction. Hypertensive patients frequently have coexisting disease conditions such as hyperlipidemia, impaired glucose metabolism, and renal impairment, which increase the risk of Cardio Vascular morbidity and mortality. When treating hypertensive patients, comprehensive management of both hypertension and concomitant Cardio Vascular Disease risk factors is essential. Some of the rare and serious Adverse Drug Reactions that occurred in patients treated with these drugs included beta-blockers causing psoriasis, calcium channel blockers causing gingival hyperplasia, peripheral oedema, Angiotensin Converting Enzyme inhibitors causing ankle oedema, and thiazide diuretics causing hyponatremia and hyperglycemia. Asymptomatic hypertension is more common and necessitates lifelong treatment with antihypertensive agents, predisposing to Adverse Drug Events.In order to improve treatment outcomes and reduce morbidity and mortality associated with adverse drug reactions, healthcare professionals must monitor adverse drug reactions in patients taking antihypertensive drugs. Keywords: Adverse drug reactions, Hypertension, hyperlipidemia, glucose metabolism

Differences in Comorbidities Explain Black-White Disparities in Outcomes After Femoropopliteal Endovascular Intervention.

Black adults have a higher incidence of peripheral artery disease and limb amputations than White adults in the United States. Given that peripheral endovascular intervention (PVI) is now the primary revascularization strategy for peripheral artery disease, it is important to understand whether racial differences exist in PVI incidence and outcomes. Data from fee-for-service Medicare beneficiaries ≥66 years of age from 2016 to 2018 were evaluated to determine age- and sex-standardized population-level incidences of femoropopliteal PVI among Black and White adults over the 3-year study period. Patients' first inpatient or outpatient PVIs were identified through claims codes. Age- and sex-standardized risks of the composite outcome of death and major amputation within 1 year of PVI were examined by race. Black adults underwent 928 PVIs per 100 000 Black beneficiaries compared with 530 PVIs per 100 000 White beneficiaries (risk ratio, 1.75 [95% CI, 1.73-1.77]; P<0.01). Black adults who underwent PVI were younger (mean age, 74.5 years versus 76.4 years; P<0.01), were more likely to be female (52.8% versus 42.7%; P<0.01), and had a higher burden of diabetes (70.6% versus 56.0%; P<0.01), chronic kidney disease (67.5% versus 56.6%; P<0.01), and heart failure (47.4% versus 41.7%; P<0.01) than White adults. When analyzed by indication for revascularization, Black adults were more likely to undergo PVI for chronic limb-threatening ischemia than White adults (13 023 per 21 352 [61.0%] versus 59 956 per 120 049 [49.9%]; P<0.01). There was a strong association between Black race and the composite outcome at 1 year (odds ratio, 1.21 [95% CI, 1.16-1.25]). This association persisted after adjustment for socioeconomic status (odds ratio, 1.08 [95% CI, 1.03-1.13]) but was eliminated after adjustment for comorbidities (odds ratio, 0.96 [95% CI, 0.92-1.01]). Among fee-for-service Medicare beneficiaries, Black adults had substantially higher population-level PVI incidence and were significantly more likely to experience adverse events after PVI than White adults. The association between Black race and adverse outcomes appears to be driven by a higher burden of comorbidities. This analysis emphasizes the critical need for early identification and aggressive management of peripheral artery disease risk factors and comorbidities to reduce Black-White disparities in the development and progression of peripheral artery disease and the risk of adverse events after PVI.

Evaluation of an Electronic Health Record Alert to Improve Screening and Management of Cardiovascular Disease and Stroke Factors in a High-Risk Population.

Cardiovascular disease and stroke risk factor screening and management by primary care providers (PCPs) have a significant impact on their patients' health. The objective of this study was to investigate the effectiveness of an electronic health record (EHR) cardiovascular disease and stroke risk alert in improving the ability of PCPs to manage risk factors among women and men aged 45 years and older. PCPs at a tertiary care hospital were randomized. The intervention group received an EHR alert, which calculated the individual patient risk and provided an order set incorporating the American Heart Association and American Stroke Association guidelines, whereas the control group used the EHR in the usual manner. Multilevel analysis compared the rate of prescriptions between the intervention and control groups. A total of 23 PCPs were randomized: 12 in the intervention group and 11 in the control group, attending to 7190 patients between September 2016 and January 2017. None of the providers in the intervention group used the programmed order set. Intervention group providers were significantly more likely to prescribe smoking cessation medication to women than to the control group (adjusted odds ratio 2.37, 95% confidence interval 1.23-4.57). There were no statistically significant differences between the intervention and control groups in the rate of other medication prescriptions. As measured by prescriptions for medications, other than those for smoking cessation, the EHR alert was not shown to be successful in increasing the management of high-risk patients. Physicians receiving numerous messages in the EHR may experience alert desensitization.

Sex Differences in Cardiac Rehabilitation Outcomes.

Cardiovascular disease is a leading cause of morbidity and mortality in males and females in the United States and globally. Cardiac rehabilitation (CR) is recommended by the American Heart Association/American College of Cardiology for secondary prevention for patients with cardiovascular disease. CR participation is associated with improved cardiovascular disease risk factor management, quality of life, and exercise capacity as well as reductions in hospital admissions and mortality. Despite these advantageous clinical outcomes, significant sex disparities exist in outpatient phase II CR programming. This article reviews sex differences that are present in the spectrum of care provided by outpatient phase II CR programming (ie, from referral to clinical management). We first review CR participation by detailing the sex disparities in the rates of CR referral, enrollment, and completion. In doing so, we discuss patient, health care provider, and social/environmental level barriers to CR participation with a particular emphasis on those barriers that majorly impact females. We also evaluate sex differences in the core components incorporated into CR programming (eg, patient assessment, exercise training, hypertension management). Next, we review strategies to mitigate these sex differences in CR participation with a focus on automatic CR referral, female-only CR programming, and hybrid CR. Finally, we outline knowledge gaps and areas of future research to minimize and prevent sex differences in CR programming.

Methodological framework for the management and mitigation of cardiovascular disease risk factors

<h3></h3> В настоящее время болезни системы кровообращения являются основной причиной смертности населения Российской Федерации (РФ). Усилия государства и общества сосредоточены преимущественно на повышении эффективности лечения. Вместе с тем профилактика сердечно-сосудистых заболеваний (ССЗ), направленная на выявление и коррекцию факторов риска (ФР), остается недостаточно эффективной. В последние годы начато создание структур по управлению сердечно-сосудистыми рисками. Однако научно обоснованные методы управления отсутствуют. С учетом этого в 2018 г. в Республике Татарстан (РТ) организована система управления ФР для профилактики развития ССЗ. <h3>ЦЕЛЬ ИССЛЕДОВАНИЯ</h3> Научно обосновать создание и функционирование системы управления ФР развития ССЗ для минимизации их уровня. <h3>МАТЕРИАЛ И МЕТОДЫ</h3> Для<b></b> управления<b></b> сердечно-сосудистыми рисками у пациентов, имеющих ФР или установленные ССЗ, создана система, объединяющая клиники, пациентов, центр управления рисками на основе использования специальной программы CVRM (CardioVascular Risk Management). Деятельность заключается в выявлении пациентов с ФР развития ССЗ и проспективного наблюдения за динамикой их уровня на фоне выполнения профилактических рекомендаций. Коррекцию ФР производили при помощи профилактического консультирования, включающего рекомендации по изменению образа жизни, направление к профильным специалистам и на диагностическое обследование. В исследовании учтены пять основных ФР и шкала SCORE. За период с 2018 по 2019 г. в программе зарегистрированы данные 111 522 пациентов, из них имеющих ФР 95 758, имеющих ССЗ 15 764. <h3>РЕЗУЛЬТАТЫ</h3> У 22 922 человек произведена оценка уровня ФР до и через 1 год после получения профилактических рекомендаций. У лиц, имеющих ФР, получено снижение их уровня на 0,7—4,2%. Уровень риска по шкале SCORE снизился на 20,5%. У пациентов, имеющих ССЗ, получено снижение уровня ФР на 1,4—2,5%. Не удалось повлиять на уровень скорости клубочковой фильтрации как у лиц, имеющих ФР, так и у пациентов с ССЗ. Не подвергся улучшению уровень индекса массы тела у пациентов с ССЗ. <h3>ВЫВОДЫ</h3> Внедрение системы управления факторами риска в здравоохранение региона стало абсолютно необходимым шагом в организации профилактики сердечно-сосудистых заболеваний. Программа CVRM зарекомендовала себя как эффективный информационный инструмент, объединяющий всех участников процесса управления рисками и позволивший существенно снизить их уровень.

Health Behavior Change Programs in Primary Care and Community Practices for Cardiovascular Disease Prevention and Risk Factor Management Among Midlife and Older Adults: A Scientific Statement From the American Heart Association.

Cardiovascular disease predominates as the leading health burden among middle-aged and older American adults, but progress in improving cardiovascular health remains slow. Comprehensive, evidenced-based behavioral counseling interventions in primary care are a recommended first-line approach for promoting healthy behaviors and preventing poor cardiovascular disease outcomes in adults with cardiovascular risk factors. Assisting patients to adopt and achieve their health promotion goals and arranging follow-up support are critical tenets of the 5A Model for behavior counseling in primary care. These 2 steps in behavior counseling are considered essential to effectively promote meaningful and lasting behavior change for primary cardiovascular disease prevention. However, adoption and implementation of behavioral counseling interventions in clinical settings can be challenging. The purpose of this scientific statement from the American Heart Association is to guide primary health care professional efforts to offer or refer patients for behavioral counseling, beyond what can be done during brief and infrequent office visits. This scientific statement presents evidence of effective behavioral intervention programs that are feasible for adoption in primary care settings for cardiovascular disease prevention and risk management in middle-aged and older adults. Furthermore, examples are provided of resources available to facilitate the widespread adoption and implementation of behavioral intervention programs in primary care or community-based settings and practical approaches to appropriately engage and refer patients to these programs. In addition, current national models that influence translation of evidence-based behavioral counseling in primary care and community settings are described. Finally, this scientific statement highlights opportunities to enhance the delivery of equitable and preventive care that prioritizes effective behavioral counseling of patients with varying levels of cardiovascular disease risk.

The varied role, scope of practice, and education of cardiovascular nurses in ESC-affiliated countries: an ACNAP survey.

Cardiovascular disease burden is increasing globally, pressuring nursing staff to deliver high-quality care across a diverse range of treatment areas. As such, an evaluation of the educational preparation of nurses is needed. To determine the current role, scope of practice, education level, and needs of cardiovascular nurses working across the European Society of Cardiology (ESC)-affiliated countries. A short survey was distributed in paper (EuroHeartCare 2018) or electronic format to nurses delivering cardiovascular care. A total of 876 cardiovascular nurses from 26 ESC-affiliated countries completed the survey. Most respondents (79%), were educated to at least bachelor level, with 46% having a masters or doctorate, and were highly motivated to continue their educational development. Despite this, a large number (44.3%) of respondents believed they were not fully prepared for their job. The main areas where further education was requested included acute care in cardiovascular disease (CVD) and CVD risk factor management. Face-to-face courses/training were the most requested delivery mode, followed by E-learning-which appears to be underutilized in this population. Awareness of the existing curricula for cardiovascular nurse education was minimal, and therefore these resources require further promotion and implementation. This international sample of cardiovascular nurses was generally educated to degree level and motivated to improve their cardiovascular knowledge. Many believed they were underprepared for their role, highlighting the need for increased investment in education. This should be focused on specific needs and delivered using a face-to-face, E-learning, or blended-learning format. Furthermore, increased signposting of existing resources is required.

Attributable societal costs of first-incident obesity-related cardiovascular comorbidities in Denmark

ABSTRACT Background: Obesity is associated with increased societal costs, primarily due to its comorbidities. The objective of this study was to estimate the 3-year attributable societal costs of the first event of cardiovascular comorbidities among people with obesity. Methods: We used an incidence-based cohort study based on Danish national registries. Attributable costs of each event were calculated as the difference between costs of individuals with an event and costs incurred by matched controls. Results: We identified 58,597 individuals with a diagnosis of obesity. On average, 2,038 individuals were diagnosed annually with one or more than ten cardiovascular comorbidities between 2007 and 2013. The 3-year attributable societal costs (health-care costs plus productivity loss) for patients of working age ranged from 8,164 EUR for other ischemic heart disease to 32,203 EUR for hemorrhagic stroke. In the incidence year, costs were mainly driven by health-care costs, while productivity loss and income transfer payments were the primary drivers in subsequent years. Conclusion: The onset of obesity-related cardiovascular comorbidities affected health-care costs and work ability to an extent where sick pay and disability pension were required. Our study demonstrates the need to intensify obesity and cardiovascular disease risk factor management to prevent costly and debilitating obesity-related comorbidities.

Capacity building of health care professionals to perform interprofessional management of non-communicable diseases in primary care \u2013 experiences from Ukraine

BackgroundNon-communicable diseases are leading causes of death and disability across the world. Countries with the highest non-communicable disease (NCD) burden in the WHO European Region are often those that have some of the greatest health system challenges for achieving good outcomes in prevention and care. The aim of this study was to evaluate the effect of an interprofessional capacity building intervention carried out in Ukraine to improve the management non-communicable diseases in primary health care.MethodsA mixed-methods evaluation study was performed in 2018 to analyse the effect of a capacity building intervention carried out for over 10,000 primary care professionals in Ukraine in 2018. Quantitative data were collected from primary health care records of intervention and control areas preceding the intervention and 1.5 to 2 years after the intervention. Altogether 2798 patient records before and 2795 after the intervention were reviewed. In control areas, 1202 patient records were reviewed. Qualitative data were collected carrying out focus group interviews for health professionals, clinic managers and patients. Also, observations of clinical practice and patient pathways were performed.ResultsThe capacity building intervention improved the capacity of professionals in detection and management of non-communicable disease risk factors. Significant improvement was seen in detection rates of both behavioural and biological risk factors and in medication prescription rates in the intervention areas. However, almost similar improvement in prescription rates was also observed in control clinics. Improvements in control of blood pressure, blood glucose and cholesterol were not seen during the evaluated implementation period. Qualitative analyses highlighted the improved knowledge and skills but challenges in changing the current practice.ConclusionsA large scale capacity building intervention improved primary health care professionals’ knowledge, skills and clinical practice on NCD risk detection and reduction. We were not able to detect improvements in treatment outcomes - at least within 1.5 to 2 years follow-up. Improvement of treatment outcomes would most likely need more comprehensive systems change.

An innovative model for management of cardiovascular disease risk factors in the low resource setting of Cambodia.

Non-communicable diseases are increasing in developing countries and control of diabetes and hypertension is needed to reduce rates of the leading causes of morbidity and mortality, stroke and ischaemic heart disease. We evaluated a programme in Cambodia, financed by a revolving drug fund, which utilizes Peer Educators to manage diabetes and hypertension in the community. We assessed clinical outcomes and retention in the programme. For all people enrolled in the programme between 2007 and 2016, the average change in blood pressure (BP) and percentage with controlled hypertension (BP < 140/<90 mmHg) or diabetes (fasting blood glucose (BG) < 7mg/dl, post-prandial BG < 130 mg/dl, or HBA1C < 7%) was calculated every 6 months from enrolment. Attrition rate in the nth year of enrolment was calculated; associations with loss to follow-up were explored using cox regression. A total of 9139 patients enrolled between January 2007 and March 2016. For all people with hypertension, mean change in systolic and diastolic BP within the first year was −15.1 mmHg (SD 23.6, P < 0.0001) and −8.6 mmHg (SD 14.0, P < 0.0001), respectively. BP control was 50.5% at year 1, peaking at 70.6% at 5.5 years. 41.3% of people with diabetes achieved blood sugar control at 6 months and 44.4% at 6.5 years. An average of 2.3 years [SD 1.9] was spent in programme. Attrition rate within year 1 of enrolment ranged from 29.8% to 61.5% with average of 44.1% [SD 10.3] across 2008–15. Patients with hypertension were more likely to leave the program compared to those with diabetes and males more likely than females. The programme shows a substantial and sustained rate of diabetes and hypertension control for those who remain in the program and could be a model for implementation in other low middle-income settings, however, further work is needed to improve patient retention.