Reductions In Major Risk Factors Research Articles

Explaining declining hip fracture rates in Norway: a population-based modelling study.

Although age-standardised hip fracture incidence has declined in many countries during recent decades, the number of fractures is forecast to increase as the population ages. Understanding the drivers behind this decline is essential to inform policy for targeted preventive measures. We aimed to quantify how much of this decline could be explained by temporal trends in major risk factors and osteoporosis treatment. We developed a new modelling approach, Hip-IMPACT, based on the validated IMPACT coronary heart disease models. The model applied sex- and age stratified hip fracture numbers and prevalence of pharmacologic treatments and risk/preventive factors in 1999 and 2019, and best available evidence for independent relative risks of hip fracture associated with each treatment and risk/preventive factor. Hip-IMPACT explained 91% (2500/2756) of the declining hip fracture rates during 1999-2019. Two-thirds of the total decline was attributed to changes in risk/preventive factors and one-fifth to osteoporosis medication. Increased prevalence of total hip replacements explained 474/2756 (17%), increased body mass index 698/2756 (25%), and increased physical activity 434/2756 (16%). Reduced smoking explained 293/2756 (11%), and reduced benzodiazepine use explained (366/2756) 13%. Increased uptake of alendronate, zoledronic acid, and denosumab explained 307/2756 (11%), 104/2756 (4%) and 161/2756 (6%), respectively. The explained decline was partially offset by increased prevalence of type 2 diabetes and users of glucocorticoids, z-drugs, and opioids. Two-thirds of the decline in hip fractures from 1999 to 2019 was attributed to reductions in major risk factors and approximately one-fifth to osteoporosis medication. The Research Council of Norway.

Personalized medicine-a modern approach for the diagnosis and management of hypertension.

The main goal of treating hypertension is to reduce blood pressure to physiological levels and thereby prevent risk of cardiovascular disease and hypertension-associated target organ damage. Despite reductions in major risk factors and the availability of a plethora of effective antihypertensive drugs, the control of blood pressure to target values is still poor due to multiple factors including apparent drug resistance and lack of adherence. An explanation for this problem is related to the current reductionist and ‘trial-and-error’ approach in the management of hypertension, as we may oversimplify the complex nature of the disease and not pay enough attention to the heterogeneity of the pathophysiology and clinical presentation of the disorder. Taking into account specific risk factors, genetic phenotype, pharmacokinetic characteristics, and other particular features unique to each patient, would allow a personalized approach to managing the disease. Personalized medicine therefore represents the tailoring of medical approach and treatment to the individual characteristics of each patient and is expected to become the paradigm of future healthcare. The advancement of systems biology research and the rapid development of high-throughput technologies, as well as the characterization of different –omics, have contributed to a shift in modern biological and medical research from traditional hypothesis-driven designs toward data-driven studies and have facilitated the evolution of personalized or precision medicine for chronic diseases such as hypertension.

Mortality decrease from cardiovascular disease in Europe: 50 % in 30 years!

Mortality decrease from cardiovascular disease in Europe: 50 % in 30 years!

Life-style characteristics and cardiovascular risk factors in regular downhill skiers: an observational study

BackgroundDownhill skiing is part of active life style in many residents of Alpine regions. However, only very little information is available whether downhill skiing on a regular basis is associated with a healthier life style resulting in the reduction of major risk factors for cardiovascular diseases and memory deficits when compared to the general population. Thus, the aim of the study was to compare life-style characteristics and cardiovascular risk factors between regular downhill skiers and the general population.MethodsSelf-reported health and life-style data were collected by questionnaire from 1259 long-term downhill skiers (971 males, aged 57.3 ± 14.6 years; 288 females, aged 47.7 ± 16.4 years) and compared with data from the general population.ResultsLong-term skiers showed more favourable life-style characteristics and a better health status than the general population. Prevalences of hypercholesterolemia, systemic hypertension, diabetes, the frequency of mental stress and the occurrence of memory deficits declined with increasing yearly skiing frequency.ConclusionLong-term alpine skiing on a regular basis may contribute to healthy aging by its association with a healthier life style.

Decline in mortality from coronary heart disease in Poland after socioeconomic transformation: modelling study

Objectives To examine how much of the observed rapid decrease in mortality from coronary heart disease in Poland after the political, social, and economic transformation in the early 1990s could...

Analyzing the Coronary Heart Disease Mortality Decline in a Mediterranean Population: Spain 1988-2005

Introduction and objectives To examine the extent to which the decrease in mortality rates in Spain between 1988 and 2005 could be explained by changes in cardiovascular risk factors and by the use of medical and surgical treatments. Methods We used the previously validated IMPACT model to examine the contributions of exposure factors (risk factors and treatments) to the main outcome, changes in the mortality rates of death from coronary heart disease, among adults 35 to 74 years of age. Main data sources included official mortality statistics, results of longitudinal studies, national surveys, randomized controlled trials, and meta-analyses. The difference between observed and expected coronary heart disease deaths in 2005 was then partitioned between treatments and risk factors. Results From 1988 to 2005, the age-adjusted coronary heart disease mortality rates fell by almost 40%, resulting in 8530 fewer coronary heart disease deaths in 2005. Approximately 47% of the fall in deaths was attributed to treatments. The major treatment contributions came from initial therapy for acute coronary syndromes (11%), secondary prevention (10%), and heart failure (9%). About 50% of the fall in mortality was attributed to changes in risk factors. The largest mortality benefit came from changes in total cholesterol (about 31% of the mortality fall) and in systolic blood pressure (about 15%). However, some substantial gender differences were observed in risk factor trends with an increase in diabetes and obesity in men and an increase in smoking in young women. These generated additional deaths. Conclusions Approximately half of the coronary heart disease mortality fall in Spain was attributable to reductions in major risk factors, and half to evidence-based therapies. These results increase understanding of past trends and will help to inform planning for future prevention and treatment strategies in low-risk populations.

Análisis de la disminución de la mortalidad por enfermedad coronaria en una población mediterránea: España 1988-2005

Introduction and objectives To examine the extent to which the decrease in coronary heart disease mortality rates in Spain between 1988 and 2005 could be explained by changes in cardiovascular risk factors and by the use of medical and surgical treatments. Methods We used the previously validated IMPACT model to examine the contributions of exposure factors (risk factors and treatments) to the main outcome, changes in the mortality rates of death from coronary heart disease, among adults 35 to 74 years of age. Main data sources included official mortality statistics, results of longitudinal studies, national surveys, randomized controlled trials, and meta-analyses. The difference between observed and expected coronary heart disease deaths in 2005 was then partitioned between treatments and risk factors. Results From 1988 to 2005, the age-adjusted coronary heart disease mortality rates fell by almost 40%, resulting in 8530 fewer coronary heart disease deaths in 2005. Approximately 47% of the fall in deaths was attributed to treatments. The major treatment contributions came from initial therapy for acute coronary syndromes (11%), secondary prevention (10%), and heart failure (9%). About 50% of the fall in mortality was attributed to changes in risk factors. The largest mortality benefit came from changes in total cholesterol (about 31% of the mortality fall) and in systolic blood pressure (about 15%). However, some substantial gender differences were observed in risk factor trends with an increase in diabetes and obesity in men and an increase in smoking in young women. These generated additional deaths. Conclusions Approximately half of the coronary heart disease mortality fall in Spain was attributable to reductions in major risk factors, and half to evidence-based therapies. These results increase understanding of past trends and will help to inform planning for future prevention and treatment strategies in low-risk populations. Full English text available from: www.revespcardiol.org

Recent Advances in Preventive Cardiology and Lifestyle Medicine

Multifactorial risk factor modification and control, especially interventions designed to reduce total cholesterol, systolic blood pressure, smoking prevalence, overweight/obesity, diabetes mellitus, and physical inactivity, can have a profound and favorable impact on decreasing the incidence of initial and recurrent cardiovascular events. Between 1980 and 2000, mortality rates from coronary heart disease (CHD) fell by >40%. Using a previously validated statistical model (IMPACT), researchers attempted to determine how much of this decrease could be explained by the use of medical and surgical treatments as opposed to changes in risk factors among US adults aged 25 to 84 years. Approximately half of the decline in cardiovascular deaths was attributed to reductions in major risk factors (obesity and diabetes mellitus were notable exceptions), and approximately half was attributed to evidence-based medical therapies (eg, secondary prevention medications, rehabilitation, and initial treatments for acute myocardial infarction [AMI]).1 In contrast, emergent and elective revascularization accounted for only 7% of the overall decline in deaths from CHD. Recently, similar results were reported in a Canadian study that evaluated the decrease in CHD mortality between 1994 and 2005.2 Over the past decade, mortality rates from CHD and stroke in the United States decreased by >25% (Figure 1).3 Although there were also impressive reductions in the prevalence of uncontrolled high blood pressure, elevated blood cholesterol, and, to a lesser extent, cigarette smoking, there was only limited impact on other risk factors, including increases in the prevalence of obesity and diabetes mellitus, and a small reduction in those not engaged in moderate or vigorous physical activity.3 These indicators represent major challenges to achieving future goals for cardiovascular health promotion and disease reduction. Figure 1. Mortality rates from coronary heart disease and stroke, rate of uncontrolled blood pressure, and prevalence of high cholesterol from 2004 to 2008. Reproduced …

Diabetes and Cardiovascular Disease

The prevalence of obesity and diabetes continues to increase rapidly in the U.S. and all over the world (1–3). Obesity and diabetes are major risk factors for cardiovascular diseases (CVDs), but despite the increase in their prevalence, there seems to be a continuous steady decline in death rates from coronary heart disease (CHD) and stroke (4). Moreover, cause-specific excess death associated with obesity has been declining despite the increase in obesity rates (5). The reason behind this apparent paradox is probably a better control of other risk factors for CVD, such as cholesterol levels, hypertension, and smoking. Several trials demonstrated that more than half the decline in deaths from CHD in the last decades may be attributable to reductions in major risk factors (6). Of all risk factors, treating high cholesterol levels had the highest impact on the decline in CHD mortality (7). This is hardly surprising because the LDL cholesterol level is the strongest determinant of CHD risk, even in diabetic patients (8). ### Prevention of CHD in diabetic patients and the question of residual risk Statins are the most effective agents in reducing the risk of CHD in diabetic patients, reducing the relative risk by about one-third (9,10). An analysis based on the UK Prospective Diabetes Study (UKPDS) risk engine demonstrated that even in the Steno-2 study, in which multifactorial intervention was used for the treatment of diabetes with an impressive reduction of both cardiovascular morbidity and mortality, lipid-lowering therapy accounted for more than 70% of CVD risk reduction (11). Actually, many more patients in the intensive therapy group achieved their cholesterol goal compared with the conventional therapy group (70 vs. 20%), while there was no difference between the groups in the attainment of their triglyceride goal (11). The main difference between the intensive and conventional treatment groups was in the use of statins (12 …

P02 Risk factor and treatment contributions to the coronary heart disease mortality decline in a low risk Mediterranean population: Spain 1988–2005

BackgroundThe “Mediterranean Paradox” means that low risk countries such as Spain experience substantially less cardiovascular mortality than North Europe or the USA. Can cardiovascular mortality fall further?ObjectiveWe examined the extent...

Cardiovascular risk factor trends and options for reducing future coronary heart disease mortality in the United States of America

To examine the potential for reducing cardiovascular risk factors in the United States of America enough to cause age-adjusted coronary heart disease (CHD) mortality rates to drop by 20% (from 2000 baseline figures) by 2010, as targeted under the Healthy People 2010 initiative. Using a previously validated, comprehensive CHD mortality model known as IMPACT that integrates trends in all the major cardiovascular risk factors, stratified by age and sex, we calculated how much CHD mortality would drop between 2000 and 2010 in the projected population of the United States aged 25-84 years (198 million). We did this for three assumed scenarios: (i) if recent risk factor trends were to continue to 2010; (ii) success in reaching all the Healthy People 2010 risk factor targets, and (iii) further drops in risk factors, to the levels already seen in the low-risk stratum. If age-adjusted CHD mortality rates observed in 2000 remained unchanged, some 388,000 CHD deaths would occur in 2010. First scenario: if recent risk factor trends continued to 2010, there would be approximately 19,000 fewer deaths than in 2000. Although improved total cholesterol, lowered blood pressure in men, decreased smoking and increased physical activity would account for some 51,000 fewer deaths, these would be offset by approximately 32,000 additional deaths from adverse trends in obesity and diabetes and in blood pressure in women. Second scenario: If Healthy People 2010 cardiovascular risk factor targets were reached, approximately 188,000 CHD deaths would be prevented. Scenario three: If the cardiovascular risk levels of the low-risk stratum were reached, approximately 372,000 CHD deaths would be prevented. Achievement of the Healthy People 2010 cardiovascular risk factor targets would almost halve the predicted CHD death rates. Additional reductions in major risk factors could prevent or postpone substantially more deaths from CHD.

Secondary prevention strategies for coronary heart disease

Patients with established coronary heart disease (CHD) have a high risk of subsequent cardiovascular events, including myocardial infarction (MI), stroke, and death from cardiovascular disease. Adherence to evidence-based secondary prevention therapies for CHD has improved in recent years but still remains suboptimal. Mortality from CHD in the United States (US) has decreased substantially in recent decades. The decline in US deaths from CHD from 1980 through 2000 has been attributed to reductions in major risk factors and utilization of evidence-based medical therapies. It has been estimated that optimization of secondary prevention strategies could save as many as 80,000 more lives per year in the US. The American College of Cardiology (ACC) and American Heart Association (AHA) updated its guidelines for secondary prevention for patients with atherosclerotic vascular disease in 2006. The guidelines emphasize evidence-based developments in the field of CHD secondary prevention and also reinforce the need to implement these recommendations in actual clinical practice through programs such as the ACC's Guidelines Applied to Practice and the AHA's Get With The Guidelines. This review will discuss the epidemiology and risk assessment of CHD, current pharmacologic and nonpharmacologic strategies available for the secondary prevention of CHD, and summarize the guidelines and evidence that support these treatment options. There will be an emphasis on antiplatelet therapy given the important role of thrombosis in clinical cardiovascular events.

Explaining the decrease in coronary heart disease mortality in Italy between 1980 and 2000.

We examined the extent to which the decrease in coronary heart disease (CHD) mortality rates in Italy could be explained by changes in cardiovascular risk factors versus the use of medical and surgical treatments. We used a validated model to combine data on changes in risk factors and uptake and effectiveness of cardiac treatments among adult men and women in Italy between 1980 and 2000. Data sources included results of published trials, meta-analyses, official statistics, longitudinal studies, and national surveys. The difference between observed and expected CHD deaths in 2000 was partitioned among treatments and risk factors. From 1980 to 2000, the age-adjusted CHD mortality rate in Italy fell among persons aged 25 to 84 years, resulting in 42 930 fewer CHD deaths in 2000. Approximately 40% of this decrease was attributed to treatments and 55% to changes in risk factors. Over half of the CHD mortality fall in Italy between 1980 and 2000 was attributable to reductions in major risk factors, mainly cholesterol and blood pressure, and less than half to evidence-based medical therapies. These results are becoming increasingly important, both for understanding past trends and for planning future prevention and treatment strategies.

Modelling the decreasing coronary heart disease mortality in Sweden between 1986 and 2002

Coronary heart disease (CHD) mortality rates have been falling in Sweden since the 1980s. We used the previously validated IMPACT CHD model to examine how much of the mortality decrease in Sweden between 1986 and 2002 could be attributed to medical and surgical treatments, and how much to changes in cardiovascular risk factors. The IMPACT mortality model was used to combine and analyse data on uptake and effectiveness of cardiological treatments and risk factor trends in Sweden. The main data sources were official statistics, national quality of care registers, published trials and meta-analyses, and national population surveys. Between 1986 and 2002, CHD mortality rates in Sweden decreased by 53.4% in men and 52.0% in women aged 25-84 years. This resulted in 13 180 fewer deaths in 2002. Approximately 36% of this decrease was attributed to treatments in individuals and 55% to population risk factor reductions. Adverse trends were seen for diabetes and overweight. More than half of the substantial CHD mortality decrease in Sweden between 1986 and 2002 was attributable to reductions in major risk factors, mainly a large decrease in total serum cholesterol. These findings emphasize the value of a comprehensive strategy that promotes primary prevention and evidence-based medical treatments, especially secondary prevention.

Physician gender is associated with the quality of type 2 diabetes care

Patient gender influences the quality of medical care whilst the role of physician gender is not well established. To investigate the influence of physician gender on quality of care in patients with type 2 diabetes. Cross-sectional study in 51 053 outpatients (48.6% male), treated by 3096 office-based physicians (66.3% male; 74.0% general practitioners, 21.8% internists and 4.2% diabetologists). Outcome measures included processes of care, intermediate outcomes and medical management. Quality of care measures were based on current ADA guidelines. Hierarchical regression models were used to avoid case-mix bias and to correct for physician-level clustering. Adjusted odds ratios were calculated controlling for age, gender, disease duration and presence of atherosclerotic disease. The patients of female physicians were more often women, more obese, older and had more often atherosclerotic disease (34% in the total cohort). The patients of female physicians more often reached target values in glycaemic control (HbA1c < 6.5%; OR 1.14; 1.05-1.24, P = 0.002), blood lipoproteins (LDL-C < 100 mg dL(-1); OR 1.16; 1.06-1.27, P = 0.002), and blood pressure (systolic values < 130 mmHg; OR 1.11; 1.02-1.22, P = 0.018). They were more likely to receive antihypertensive drug therapy in general (OR 1.35; 1.24-1.46, P < 0.0001) and angiotensin converting enzyme (ACE) inhibitors in particular (OR 1.17; 1.09-1.25, P < 0.0001). The patients of female physicians less often performed glucose self-monitoring (OR 0.83; 0.76-0.91, P < 0.0001) and less often received oral hypoglycaemic agents (OR 0.88; 0.82-0.95, P = 0.001). Physician gender influences quality of care in patients with type 2 diabetes. Female physicians provide an overall better quality of care, especially in prognostically important risk management.

Explaining the Decrease in U.S. Deaths from Coronary Disease, 1980–2000

Mortality from coronary heart disease in the United States has decreased substantially in recent decades. We conducted a study to determine how much of this decrease could be explained by the use of medical and surgical treatments as opposed to changes in cardiovascular risk factors. We applied a previously validated statistical model, IMPACT, to data on the use and effectiveness of specific cardiac treatments and on changes in risk factors between 1980 and 2000 among U.S. adults 25 to 84 years old. The difference between the observed and expected number of deaths from coronary heart disease in 2000 was distributed among the treatments and risk factors included in the analyses. From 1980 through 2000, the age-adjusted death rate for coronary heart disease fell from 542.9 to 266.8 deaths per 100,000 population among men and from 263.3 to 134.4 deaths per 100,000 population among women, resulting in 341,745 fewer deaths from coronary heart disease in 2000. Approximately 47% of this decrease was attributed to treatments, including secondary preventive therapies after myocardial infarction or revascularization (11%), initial treatments for acute myocardial infarction or unstable angina (10%), treatments for heart failure (9%), revascularization for chronic angina (5%), and other therapies (12%). Approximately 44% was attributed to changes in risk factors, including reductions in total cholesterol (24%), systolic blood pressure (20%), smoking prevalence (12%), and physical inactivity (5%), although these reductions were partially offset by increases in the body-mass index and the prevalence of diabetes, which accounted for an increased number of deaths (8% and 10%, respectively). Approximately half the decline in U.S. deaths from coronary heart disease from 1980 through 2000 may be attributable to reductions in major risk factors and approximately half to evidence-based medical therapies.

Life-years-gained from population risk factor changes and modern cardiology treatments in Ireland

Coronary heart disease (CHD) mortality rates in Ireland have halved since the mid-1980s, and adult life expectancy has also steadily improved. This study estimated the life-years-gained by CHD treatments and by changes in cardiovascular risk factor levels. A previously validated Irish IMPACT CHD mortality model was used to integrate large amounts of data on (i) patient numbers, (ii) treatment uptake, (iii) risk factor trends, (iv) effectiveness of cardiology treatments and risk factor reductions, and (v) median survival in patients with and without CHD, all stratified by age and sex. Results were tested in rigorous sensitivity analyses. There were 3763 fewer CHD deaths than expected in 2000 compared with the base year, 1985. This resulted in approximately 44,060 life-years-gained among people aged 25-84. Specific medical and surgical treatments given in 2000 for CHD patients together gained approximately 14,505 life-years. Population changes in cholesterol and smoking levels accounted for some 32,705 life-years-gained, 66% from reductions in cholesterol alone. Adverse changes in obesity and diabetes resulted in a loss of approximately 3670 life-years. Use of modern cardiology treatments in Ireland from 1985 to 2000 gained many thousands of life-years. However, twice as many life-years were generated by relatively modest reductions in major risk factors. Effective policies, such as the promotion of healthy diets, and weight reduction, together with the recent nationwide workplace smoking ban, will be essential to maintain and further enhance health gain.

Commentary: Predicting future coronary heart disease deaths in Finland and elsewhere

Commentary: Predicting future coronary heart disease deaths in Finland and elsewhere

Mortality reductions in patients receiving exercise-based cardiac rehabilitation: how much can be attributed to cardiovascular risk factor improvements?

It is unclear how much of the reduction in cardiac mortality in coronary heart disease (CHD) patients with exercise training is the result of direct effects on the heart and coronary vasculature, or to indirect effects, via primary risk factors. The aim of this article was to quantify the cardiac mortality benefits of exercise-based rehabilitation attributable to risk factor reductions versus the direct effects on the heart and vasculature. The IMPACT coronary heart disease model was used to examine the reduction in cardiac mortality attributable to changes in risk factors from a meta-analysis of cardiac rehabilitation randomized, controlled trials. Patients were receiving rehabilitation following an acute myocardial infarction, angina pectoris or revascularization. Outcomes considered were primary risk factors (total cholesterol, systolic blood pressure and smoking behaviour) and cardiac mortality. Nineteen exercise-only cardiac rehabilitation trials (including 2984 patients) were identified. Across these trials, exercise training reduced pooled cardiac mortality by 28% (relative risk, 0.72, 95% confidence interval 0.55-0.95), with 30 fewer deaths than in the control group. Applying the CHD model, approximately 17 (58%) of these 30 fewer deaths were attributable to reductions in major cardiovascular risk factors: 7.1 deaths (minimum estimate 6.2, maximum estimate 9.5) attributable to an 18% reduction in smoking prevalence; 5.9 deaths (minimum -0.6, maximum 12.6) to a 0.11 mmol/l reduction in cholesterol, and 4.4 deaths (-1.0 minimum, 6.7 maximum) to a 2.0 mmHg reduction in systolic blood pressure. Approximately half of the 28% reduction in cardiac mortality achieved with exercise-based cardiac rehabilitation may be attributed to reductions in major risk factors, particularly smoking.

LIFE-YEARS GAINED FROM MODERN CARDIOLOGICAL TREATMENTS AND POPULATION RISK FACTOR CHANGES IN ENGLAND AND WALES, 1981–2000

Objectives. We estimated life-years gained from cardiological treatments and cardiovascular risk factor changes in England and Wales between 1981 and 2000.Methods. We used the IMPACT model to integrate data on the number of coronary heart disease patients, treatment uptake and effectiveness, risk factor trends, and median survival in coronary heart disease patients.Results. Compared with 1981, there were 68230 fewer coronary deaths in 2000. Approximately 925415 life-years were gained among people aged 25–84 years (range: 745 195–1 138 655). Cardiological treatments for patients accounted for approximately 194145 life-years gained (range: 142505–259225), and population risk factor changes accounted for approximately 731270 life-years gained (range; 602695–879430).Conclusions. Modest reductions in major risk factors led to gains in life-years 4 times higher than did cardiological treatments. Effective policies to promote healthy diets and physical activity might achieve even greater gains.