Swedish Primary Care Cardiovascular Database Research Articles

Long-term secondary prevention and outcome following acute coronary syndrome: real-world results from the Swedish Primary Care Cardiovascular Database.

Most studies of treatment adherence after acute coronary syndrome (ACS) are based on prescribed drugs and lack long-term follow-up or consecutive data on risk factor control. We studied the long-term treatment adherence, risk factor control, and its association to recurrent ACS and death. We retrospectively included 3765 patients (mean age 75 years, 40% women) with incident ACS from 1 January 2006 until 31 December 2010 from the Swedish Primary Care Cardiovascular Database of Skaraborg. All patients were followed until 31 December 2014 or death. We recorded blood pressure (BP), low-density lipoprotein cholesterol (LDL-C), recurrent ACS, and death. We used data on dispensed drugs to calculate the proportion of days covered for secondary prevention medications. Cox regressions were used to analyse the association of achieved BP and LDL-C to recurrent ACS and death. The median follow-up time was 4.8 years. The proportion of patients that reached BP of <140/90 mm Hg was 58% at Year 1 and 66% at Year 8. 65% of the patients reached LDL-C of <2.5 mmol/L at Year 1 and 56% at Year 8; however, adherence to statins varied from 43% to 60%. Only 62% of the patients had yearly measured BP, and only 28% yearly measured LDL-C. Systolic BP was not associated with a higher risk of recurrent ACS or death. Low-density lipoprotein cholesterol of 3.0 mmol/L was associated with a higher risk of recurrent ACS {hazard ratio [HR] 1.19 [95% confidence interval (CI) 1.00-1.40]} and death HR [1.26 (95% CI 1.08-1.47)] compared with an LDL-C of 1.8 mmol/L. This observational long-term real-world study demonstrates low drug adherence and potential for improvement of risk factors after ACS. Furthermore, the study confirms that uncontrolled LDL-C is associated with adverse outcome even in this older population.

PARACETAMOL AND BLOOD PRESSURE CONTROL IN 45211 PATIENTS TREATED FOR HYPERTENSION: A CROSS-SECTIONAL STUDY FROM THE SWEDISH PRIMARY CARE CARDIOVASCULAR DATABASE

Objective: Paracetamol (acetaminophen) is widely recommended for analgetic and antipyretic indications due to its perceived high safety. However, studies have shown contradicting results regarding the effect of paracetamol on blood pressure (BP). We aimed to study how regular paracetamol use could affect BP control in patients on antihypertensive mediation. Design and method: Data for 42 511 patients attending primary care and a documented diagnosis of hypertension before 2007 (to rule out new onset of hypertension) and with 1 or more BP measurements recorded 2007–2008 were collected from the Swedish primary care cardiovascular database (SPCCD). There were 8 367 paracetamol users, defined as 1 or more dispensed prescriptions 6 months prior to the last BP recorded, and 34 144 non-users of paracetamol. Target BP was set to &lt;140/90 mm Hg. Dose-response relationships were examined by the number of defined daily doses (DDD) dispensed. Multivariate linear regression analyses accounted for potential confounders. Results: Paracetamol users were older, had higher creatinine levels, more often diabetes, cardiovascular diseases and musculoskeletal diseases, and lower educational level than non-users (all P &lt; 0.001), but attained target systolic and diastolic BP to similar degrees (58 and 93% vs 58 and 92%, respectively). There were no relations between number of DDD and systolic and diastolic BP in paracetamol users, also when DDD deciles were evaluated to account for the low proportion of patients with high DDD dispensed (all R2 &lt;0.001). Sensitivity analyses including dispensed prescriptions of paracetamol 3 months before and 6 months after the first BP measurement provided similar results. Paracetamol had no impact on attaining target BP in subgroup analyses on patients with diabetes, musculoskeletal diseases, with concomitant use of NSAID, or in relation to number of antihypertensive medications (suggesting severity of hypertensive disease). Conclusions: Concomitant use of paracetamol does not impair the ability to reach target BP in hypertensive patients. No dose-response relationship was observed between dispensed prescriptions of paracetamol and BP.

Long-term risk factor control after acute coronary syndrome; results from the Swedish primary care cardiovascular database

Abstract Background Most secondary prevention studies after acute coronary syndrome (ACS) have relatively short follow-up time, and less is known about long-term risk factor control in patients after ACS. Purpose We aimed to study and describe the long-term risk factor control, treatment adherence and outcome after ACS. Methods We identified 3765 patients (mean age 75 years, 40% women) with an incident ACS between 2006 and 2010 in the Swedish Primary Care Cardiovascular Database. All participants were followed from index ACS until 31 December 2014 or death. We annually recorded blood pressure, low density lipoprotein cholesterol (LDL-C), dispensed prescription of drugs, recurrent ACS, and death. Data were collected from electronic medical records at the primary care centres, the Swedish Prescribed Drug Register, the Swedish Patient Register, and the Cause of Death Register. We calculated annually proportion of days covered (PDC) for secondary prevention medication. PDC value of ≥80% was considered cut off for medication adherence. Results The median follow-up time was 4.8 years (min 1.8 and max 8.0). 1890 new ACS-events were recorded during the follow up; the annual incidence of recurrent ACS was 17.3%, 12.9%, 8.9%, 8.0%, 7.6%, 6.5%, 5.2%, and 5.0% (for year 1 to year 8 respectively). 1859 (49.4%) patients died during the follow up. The annual incidence of death was 19.9%, 7.9%, 7.1%, 8.3%, 7.9%, 8.2%, 6.7%, and 6.4% (for year 1 to year 8 respectively). The annual proportion of patients that achieved the blood pressure target &amp;lt;140/90 mm Hg was 57.8%, 60.9%, 62.7%, 63.3%, 64.9%, 63.1%, 62.4%, and 66.1% (for year 1 to year 8 respectively). The annual mean number of antihypertensive medications for each patient was 1.5, 1.3, 1.3, 1.3, 1.4, 1.4, 1.4, and 1.5 (for year 1 to year 8 respectively). The annual proportion of patients that achieved LDL-C &amp;lt;1.8 mmol/L was 23.1%, 21.7%, 19.8%, 18.2%, 15.7%, 19.6%, 18.3%, and 16.7% (for year 1 to year 8 respectively). The annual proportion of patients in treatment with statins was 55.3%, 57.5%, 58.7%, 59.2%, 63.0%, 63.7%, 64.1%, and 67.7% (for year 1 to year 8 respectively). The annual proportion of patients in treatment with acetylsalicylic acid was 79.6%, 76.4%, 76.2%, 78.9%, 78.3%, 79.2%, and 80.8% % (for year 1 to year 8 respectively). The annual proportion of patients in treatment with P2Y12-inhibitors was 24.3%, 7.2%, 5.4%, 6.0%, 7.2%, 8.1%, 7.9% and 8.2% (for year 1 to year 8 respectively). Conclusion This retrospective long-term real-world study from primary care demonstrates a large potential for improvement of risk factor control in patients after ACS. More specific, this study demonstrates underutilized treatment with antihypertensive medication and statins, while adherence to antiplatelet therapy was found to be high. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Astra Zeneca

Prediabetes and incident heart failure in hypertensive patients: Results from the Swedish Primary Care Cardiovascular Database

Backgrounds and aimsThe cardiovascular risk conferred by concomitant prediabetes in hypertension is unclear. We aimed to examine the impact of prediabetes on incident heart failure (HF) and all-cause mortality, and to describe time in therapeutic blood pressure range (TTR) in a hypertensive real-world primary care population. Methods and resultsIn this retrospective cohort study, 9628 hypertensive individuals with a fasting plasma glucose (FPG) in 2006–2010 but no diabetes, cardiovascular or renal disease were followed to 2016; median follow-up was 9 years. Prediabetes was defined as FPG 5.6–6.9 mmol/L, and in a secondary analysis as 6.1–6.9 mmol/L. Study outcomes were HF and all-cause mortality. Hazard ratios (HR) were compared for prediabetes with normoglycemia using Cox regression. All blood pressure values from 2001 to the index date (first FPG in 2006–2010) were used to calculate TTR. At baseline, 51.4% had prediabetes. The multivariable-adjusted HR (95% confidence intervals) was 0.86 (0.67–1.09) for HF and 1.06 (0.90–1.26) for all-cause mortality. For FPG defined as 6.1–6.9 mmol/L, the multivariable-adjusted HR were 1.05 (0.80–1.39) and 1.42 (1.19–1.70), respectively. The prediabetic group had a lower TTR (p < 0.05). ConclusionsPrediabetes was not independently associated with incident HF in hypertensive patients without diabetes, cardiovascular or renal disease. However, prediabetes was associated with all-cause mortality when defined as FPG 6.1–6.9 mmol/L (but not as 5.6–6.9 mmol/L). TTR was lower in the prediabetic group, suggesting room for improved blood pressure to reduce incident heart failure in prediabetes.

Socioeconomic status affects achievement of blood pressure target in hypertension: contemporary results from the Swedish primary care cardiovascular database

Objective To assess the relation between socioeconomic status and achievement of target blood pressure in hypertension. Design Retrospective longitudinal cohort study between 2001 and 2014. Setting Primary health care in Skaraborg, Sweden. Subjects 48,254 patients all older than 30 years, and 53.3% women, with diagnosed hypertension. Main outcome measures Proportion of patients who achieved a blood pressure target <140/90 mmHg in relation to the country of birth, personal disposable income, and educational level. Results Patients had a lower likelihood of achieving the blood pressure target if they were born in a Nordic country outside Sweden [risk ratio 0.92; 95% confidence interval (CI) 0.88–0.97], or born in Europe outside the Nordic countries (risk ratio 0.87; 95% CI 0.82–0.92), compared to those born in Sweden. Patients in the lowest income quantile had a lower likelihood to achieve blood pressure target, as compared to the highest quantile (risk ratio 0.93; 95% CI 0.90–0.96). Educational level was not associated with outcome. Women but not men in the lowest income quantile were less likely to achieve the blood pressure target. There was no sex difference in achieved blood pressure target with respect to the country of birth or educational level. Conclusion In this real-world population of primary care patients with hypertension in Sweden, being born in a foreign European country and having a lower income were factors associated with poorer blood pressure control. KEY POINTS The association between socioeconomic status and achieving blood pressure targets in hypertension has been ambiguous. •In this study of 48,254 patients with hypertension, lower income was associated with a reduced likelihood to achieve blood pressure control. •Being born in a foreign European country is associated with a lower likelihood to achieve blood pressure control. •We found no association between educational level and achieved blood pressure control.

Blood pressure levels and risk of haemorrhagic stroke in patients with atrial fibrillation and oral anticoagulants: results from The Swedish Primary Care Cardiovascular Database of Skaraborg.

To assess the risk of haemorrhagic stroke at different baseline SBP levels in a primary care population with hypertension, atrial fibrillation and newly initiated oral anticoagulants (OACs). We identified 3972 patients with hypertension, atrial fibrillation and newly initiated OAC in The Swedish Primary Care Cardiovascular Database of Skaraborg. Patients were followed from 1 January 2006 until a first event of haemorrhagic stroke, death, cessation of OAC or 31 December 2016. We analysed the association between continuous SBP and haemorrhagic stroke with a multivariable Cox regression model and plotted the hazard ratio as a function of SBP with a restricted cubic spline with 130 mmHg as reference. There were 40 cases of haemorrhagic stroke during follow-up. Baseline SBP in the 145-180 mmHg range was associated with a more than doubled risk of haemorrhagic stroke, compared with a SBP of 130 mmHg. In this cohort of primary care patients with hypertension and atrial fibrillation, we found that baseline SBP in the 145-180 mmHg range, prior to initiation of OAC, was associated with a more than doubled risk of haemorrhagic stroke, as compared with an SBP of 130 mmHg. This suggests that lowering SBP to below 145 mmHg, prior to initiation of OAC, may decrease the risk of haemorrhagic stroke in patients with hypertension and atrial fibrillation.

Country of birth and mortality risk in hypertension with and without diabetes: the Swedish primary care cardiovascular database.

Hypertension and diabetes are common and are both associated with high cardiovascular morbidity and mortality. We aimed to investigate associations between mortality risk and country of birth among hypertensive individuals in primary care with and without concomitant diabetes, which has not been studied previously. In addition, we aimed to study the corresponding risks of myocardial infarction and ischemic stroke. This observational cohort study of 62 557 individuals with hypertension diagnosed 2001-2008 in the Swedish Primary Care Cardiovascular Database assessed mortality by the Swedish Cause of Death Register, and myocardial infarction and ischemic stroke by the National Patient Register. Cox regression models were used to estimate study outcome hazard ratios by country of birth and time updated diabetes status, with adjustments for multiple confounders. During follow-up time without diabetes using Swedish-born as reference, adjusted mortality hazard ratios per country of birth category were Finland: 1.26 (95% confidence interval 1.15-1.38), high-income European countries: 0.84 (0.74-0.95), low-income European countries: 0.84 (0.71-1.00) and non-European countries: 0.65 (0.56-0.76). The corresponding adjusted mortality hazard ratios during follow-up time with diabetes were high-income European countries: 0.78 (0.63-0.98), low-income European countries: 0.74 (0.57-0.96) and non-European countries: 0.56 (0.44-0.71). During follow-up without diabetes, the corresponding adjusted hazard ratio of myocardial infarction was increased for Finland: 1.16 (1.01-1.34), whereas the results for ischemic stroke were inconclusive. In Sweden, hypertensive immigrants (with the exception for Finnish-born) with and without diabetes have a mortality advantage, as compared to Swedish-born.

The impact of diabetes, education and income on mortality and cardiovascular events in hypertensive patients: A cohort study from the Swedish Primary Care Cardiovascular Database (SPCCD).

ObjectiveIn this study we aimed to estimate the effect of diabetes, educational level and income on the risk of mortality and cardiovascular events in primary care patients with hypertension.MethodsWe followed 62,557 individuals with hypertension diagnosed 2001–2008, in the Swedish Primary Care Cardiovascular Database. Study outcomes were death, myocardial infarction, and ischemic stroke, assessed using national registers until 2012. Cox regression models were used to estimate adjusted hazard ratios of outcomes according to diabetes status, educational level, and income.ResultsDuring follow-up, 13,231 individuals died, 9981 were diagnosed with diabetes, 4431 with myocardial infarction, and 4433 with ischemic stroke. Hazard ratios (95% confidence intervals) for diabetes versus no diabetes: mortality 1.57 (1.50–1.65), myocardial infarction 1.24 (1.14–1.34), and ischemic stroke 1.17 (1.07–1.27). Hazard ratios for diabetes and ≤9 years of school versus no diabetes and >12 years of school: mortality 1.56 (1.41–1.73), myocardial infarction 1.36 (1.17–1.59), and ischemic stroke 1.27 (1.08–1.50). Hazard ratios for diabetes and income in the lowest fifth group versus no diabetes and income in the highest fifth group: mortality 3.82 (3.36–4.34), myocardial infarction 2.00 (1.66–2.42), and ischemic stroke 1.91 (1.58–2.31).ConclusionsDiabetes combined with low income was associated with substantial excess risk of mortality, myocardial infarction and ischemic stroke among primary care patients with hypertension.

Relation Between Lipid Profile and New-Onset Atrial Fibrillation in Patients With Systemic Hypertension (From the Swedish Primary Care Cardiovascular Database [SPCCD

The relation between dyslipidemia and atrial fibrillation (AF) development is still controversial. To assess the impact of lipid profile on new-onset AF, we followed 51,020 primary-care hypertensive patients without AF at baseline. After a mean follow-up time of 3.5 years, AF occurred in 2,389 participants (4.7%). We evaluated the association between total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides, and new-onset AF. In a Poisson regression model fully adjusted for common risk factors of AF, we found that 1.0 mmol/l (39 mg/dl) increase in total cholesterol was associated with 19% lower risk of new-onset AF (95% confidence interval [CI] 9% to 28%), and 1.0 mmol/l (39 mg/dl) increase in low-density lipoprotein cholesterol was associated with 16% lower risk of new-onset AF (95% CI 3% to 27%). Gender-specific Poisson regression analyses revealed that increase in total cholesterol by 1.0 mmol/l (39 mg/dl) was found to be associated with lower risk of new-onset AF with 21% in men (95% CI 8% to 32%), and 18% in women (95% CI 1% to 31%). There was no association between high-density lipoprotein cholesterol or triglycerides and new-onset AF, neither in the whole population with respect to separate gender. In conclusion, in a large hypertensive population we found an inverse association between total cholesterol and new-onset AF for both men and women. Our results confirm previous reports of a dyslipidemia paradox, and extend these observations to the hypertensive population.

Cardiovascular outcome in treatment-resistant hypertension: results from the Swedish Primary Care Cardiovascular Database (SPCCD).

To assess cardiovascular outcome in patients with treatment-resistant hypertension (TRH) compared with patients with nontreatment-resistant hypertension (HTN). Cohort study with data from 2006 to 2012 derived from the Swedish Primary Care Cardiovascular Database with hypertensive patients aged at least 30 years. TRH was defined as blood pressure at least 140/90 mmHg despite medication adherence to three or more dispensed antihypertensive drug classes. Patients with cardiovascular comorbidity were excluded. The association between TRH and cardiovascular events with adjustment for important confounders was analyzed. We included 4317 TRH patients and 32 282 HTN patients. TRH patients (61% women) were older (70 vs. 66 years), had higher SBP (152 vs. 141 mmHg) and more diabetes (30 vs. 20%) (P < 0.001 for all) compared with HTN patients. Mean follow-up time was 4.3 years. In the adjusted analysis, TRH patients had an increased risk for total mortality [hazard ratio 1.12; 95% confidence interval (CI), 1.03-1.23], cardiovascular mortality (hazard ratio 1.20; 95% CI, 1.03-1.40) and incident heart failure (hazard ratio 1.34; 95% CI, 1.17-1.54) but not for incident stroke (hazard ratio 1.03; 95% CI, 0.90-1.19) or transitoric ischemic attack (hazard ratio 1.12; 95% CI, 0.86-1.46) compared with HTN patients. Patients with TRH have a poor prognosis beyond blood pressure level, compared with hypertensive patients without TRH. In particular, the high risk for heart failure is of clinical importance and merits further investigation.

Drug adherence in treatment resistant and in controlled hypertension-Results from the Swedish Primary Care Cardiovascular Database (SPCCD).

To assess drug adherence in patients treated with ≥3 antihypertensive drug classes, with both controlled and uncontrolled blood pressure and describe associated factors for nonadherence. Patients with hypertension, without cardiovascular comorbidity, aged >30years treated with ≥3 antihypertensive drug classes were followed for 2years. Both patients with treatment resistant hypertension (TRH) and patients with controlled hypertension were included. Clinical data were derived from a primary care database. Pharmacy refill data from the Swedish Prescribed drug registry was used to calculate proportion of days covered (PDC). Patients with a PDC level≥80% were included. We found 5846 patients treated ≥3 antihypertensive drug classes, 3508 with TRH (blood pressure≥140/90), and 2338 with controlled blood pressure (<140/90mmHg). TRH patients were older (69.1 vs 65.8years, P<.0001) but had less diabetes (28.5 vs 31.7%, P<.009) compared with patients with controlled blood pressure. The proportion of patients with PDC≥80% declined with 11% during the first year in both groups. Having diabetes was associated with staying adherent at 1year (RR 0.82; 95% CI, 0.68-0.98) whilst being born outside Europe was associated with nonadherence at one and (RR 2.05; 95% CI, 1.49-2.82). Patients with multiple antihypertensive drug therapy had similar decline in adherence over time regardless of initial blood pressure control. Diabetes was associated with better adherence, which may imply that the structured caregiving of these patients enhances antihypertensive drug treatment.

Antihypertensive control and new-onset atrial fibrillation: Results from the Swedish Primary Care Cardiovascular Database (SPCCD).

Background Atrial fibrillation is associated with increased cardiovascular morbidity and mortality. Hypertension is an important risk factor for the development of atrial fibrillation. Aim This study assessed the relationship between blood pressure control and new-onset atrial fibrillation in hypertensive patients. Methods and results We followed 45,530 hypertensive patients with no previously documented atrial fibrillation, attending primary healthcare in Sweden during 2001-2008. After a mean follow-up of 3.5 years 2057 patients (4.5%) developed atrial fibrillation. Compared to patients with no atrial fibrillation, the new-onset atrial fibrillation group (after adjustment for age, sex, diabetes mellitus, heart failure, ischaemic heart disease, cerebrovascular disease and number of visits) had higher mean in-treatment systolic blood pressure (SBP) and diastolic blood pressure of 3.8 mmHg (95% confidence interval (CI) 3.0-4.6; P < 0.0001) and 1.6 mmHg (95% CI 1.2-2.0; P < 0.0001), respectively. Similarly, mean in-treatment pulse pressure in the new-onset atrial fibrillation group was 2.2 mmHg (95% CI 1.6-2.9; P < 0.001) higher. In a logistic regression analysis, achieved SBP ≥ 140 mmHg was associated with a higher risk of new-onset atrial fibrillation, compared to SBP 130-139 mmHg (odds ratio (OR) 1.5; 95% CI 1.3-1.7) and to SBP < 130 mmHg (OR 1.3; 95% CI 1.1-1.5). There was no difference in risk for new-onset AF between SBP 130-139 and <130 mmHg (OR 0.9; 95% CI 0.7-1.1). Conclusion The present findings indicate that blood pressure control in hypertension is associated with a lower risk of new-onset atrial fibrillation.

Non-steroidal anti-inflammatory drugs and blood pressure control in patients treated for hypertension: results from the Swedish primary care cardiovascular database

Purpose: The aim of this observational cohort study was to investigate blood pressure level and the possibility to reach target blood pressure during concomitant use of NSAID in hypertensive patients.Materials and methods: From the Swedish primary care cardiovascular database (SPCCD) a cohort of 5463 patients (2007 to 2008) with at least one prescription of NSAID dispensed 6 months prior to the last blood pressure measurement were included. Clinical data were extracted from computerized medical records and linked to the Prescribed Drug Register. Multivariable logistic regression models were used for analysis.Results: Patients with NSAID usage were younger, more often female, with lower creatinine concentrations, more musculoskeletal diagnosis and less cardiovascular comorbidity compared to patients without dispensed NSAID (p < .0001 for all). Regular dose of NSAID was not associated with a decreased possibility to reach target blood pressure. A correlation between the dose of naproxen and an increase in SBP of 7 mm Hg was found. Impairment in renal function did not influence the association between blood pressure control and NSAID (p = .27).Conclusion: In hypertensive patients with concomitant use of NSAID the chance to reach target blood pressure was not impaired. In intermediate and frequent users of NSAID there was a dose response relation with naproxen and SBP which was not found in diclofenac and ibuprofen.

Thiazide diuretics and the risk of osteoporotic fractures in hypertensive patients. Results from the Swedish Primary Care Cardiovascular Database.

The objective is to investigate if treatment with thiazides reduces the risk of osteoporotic fractures in hypertensive patients in primary healthcare. Further we aimed to examine the impact of duration of thiazide use, the consequences of discontinuation of treatment, and the possible difference in effect between men and women. This retrospective cohort study includes 57 822 individuals, 45 years and older, diagnosed with hypertension during 2001-2008 in the Swedish Primary Care Cardiovascular Database. Patients were followed from 1 January 2006 (or the date of their first diagnosis of hypertension if that date came later), until they had an incident osteoporotic fracture, died, or reached the end of the study at 31 December 2012. Patients exposed to thiazides were compared with patients never exposed to thiazides. Current use of thiazides was associated with significantly reduced risk of osteoporotic fractures [hazards ratio 0.89; 95% confidence interval (CI) 0.81-0.98], and increased with longer treatment periods (hazards ratio 0.87; 95% CI 0.78-0.97 after 2 years). However, discontinuation of thiazides increased the risk of osteoporotic fractures (hazards ratio 1.18; 95% CI 1.04-1.33), but attenuated with longer duration past treatment period. When analyzing men and women separately, similar results were seen, although only significant in men. This large observational study confirms that thiazide therapy in hypertensive patients is associated with a reduced risk of osteoporotic fractures. The protective effect increased with longer treatment periods. However, discontinuation of treatment increased the risk of fractures, which emphasizes the importance of continuous treatment.

Persistence to antihypertensive drug classes: A cohort study using the Swedish Primary Care Cardiovascular Database (SPCCD).

The aim was to study persistence to, and switching between, antihypertensive drug classes and to determine factors associated with poor persistence.This was an observational cohort study. The Swedish Primary Care Cardiovascular Database includes data from medical records, socioeconomic data, filled prescriptions, and hospitalizations from national registries for 75,000 patients with hypertension. Patients included in the study were initiated on antihypertensive drug treatment in primary healthcare in 2006 to 2007. We defined class persistence as the proportion remaining on the initial drug class, including 30 days of gap. Patients with a filled prescription of another antihypertensive drug class after discontinuation of the initial drug, including 30 days of gap, were classified as switchers. Persistence to the various drug classes were compared with that for diuretics.We identified 4997 patients (mean age 60 ± 12 years in men and 63 ± 13 years in women). Out of these, 95 (2%) filled their first prescription for fixed combination therapy and 4902 (98%) for monotherapy, including angiotensin converting enzyme inhibitors (37%), angiotensin receptor blockers (4%), beta blockers (21%), calcium channel blockers (8%), and diuretics (28%). Persistence to the initial drug class was 57% after 1 year and 43% after 2 years. There were no differences in persistence between diuretics and any of the other antihypertensive drug classes, after adjustment for confounders. Discontinuation (all adjusted) was more common in men (P = 0.004), younger patients (P < 0.001), those with mild systolic blood pressure elevation (P < 0.001), and patients born outside the Nordic countries (P < 0.001). Among 1295 patients who switched drug class after their first prescription, only 21% had a blood pressure recorded before the switch occurred; and out them 69% still had high blood pressures.In conclusion, there appears to be no difference in drug class persistence between diuretics and other major antihypertensive drug classes, when factors known to be associated with poor persistence are taken into account.

Prevalence of treatment-resistant hypertension and important associated factors—results from the Swedish Primary Care Cardiovascular Database

We aimed to describe the prevalence, treatment, and associated comorbidity of treatment-resistant hypertension (TRH). This registry-based cohort study from The Swedish Primary Care Cardiovascular Database assessed 53,090 hypertensive patients attending primary care. Patients adherent to antihypertensive treatment measured by pharmacy fills and with proportion of days covered ≥80% were included. The prevalence of TRH was 17% when considering all current TRH definitions. Adherence to mineralocorticoid receptor antagonists differed between TRH- and non-TRH patients (8 vs. 4%). Higher frequencies (prevalence ratio and 95% confidence intervals) of diabetes mellitus (1.59, 1.53–1.66), heart failure (1.55, 1.48–1.64), atrial fibrillation (1.33, 1.27–1.40), ischemic heart disease (1.25, 1.20–1.30), and chronic kidney disease (1.38, 1.23–1.54) were seen in patients with TRH compared to patients without TRH. These findings, in a population with valid data on medication adherence, emphasize a broad preventive approach for these high-risk patients.

OP.2C.04] THE BLOOD PRESSURE LOWERING EFFECT ON NEW-ONSET ATRIAL FIBRILLATION

Objective: The aim of the current study was to evaluate the effect of antihypertensive treatment on new-onset atrial fibrillation (AF) in relation to the blood pressure level. Design and method: This retrospective longitudinal study is based on the Swedish Primary Care Cardiovascular Database (SPCCD) which consists of a large primary health care cohort of 74751 patients with hypertension. All patients included in SPCCD during 2002 to 2008 without any AF diagnosis at baseline were included in the current study. All participants were followed until 31st December 2008 or until diagnosed with AF. The blood pressure levels of the participants who did not developed AF were compared with those who developed AF. Results: A total of 32193 patients with no AF at baseline and blood pressure registered through the whole follow-up were included in the analysis. During this period 1750 participants (5.4%) developed AF. The participants who developed AF had the last year of the follow-up a mean systolic blood pressure of 151 mmHg compared to 145 mmHg for the rest of the participants. Hence, participants who developed new-onset AF had 5.8 mmHg significantly higher blood pressure (p-value < 0.0001). This difference remained significant even after adjustment for age and number of antihypertensive medicines. Conclusions: The current study demonstrate that development of AF among hypertensive patients is related to higher blood pressure levels regardless antihypertensive treatment. Thus, blood pressure lowering treatment per se seems to have a protective effect on new-onset AF.

PP.LB01.10] PREFERRED DRUG CLASSES TO INITIATE ANTIHYPERTENSIVE TREATMENT IN SWEDISH PRIMARY CARE

Objective: To assess which antihypertensive drug classes are the most preferred in patients newly initiated on treatment in Swedish primary care. Design and method: The Swedish Primary Care Cardiovascular Database (SPCCD) comprises almost 75000 patients attending primary care with a diagnosis of hypertension in two geographically defined rural and urban regions in Sweden. All primary care physicians and patients at the 48 primary care centres are included and data are automatically extracted, minimizing potential selection bias due to voluntary participation. The current observational cohort study included patients aged > = 30 years with previously untreated hypertension and a first prescription of an antihypertensive drug during 2006–2007. Preferred drug class was analysed according to sex, age and concurrent diseases. Results: We identified 5225 patients (mean age 61.4 years, 55% women) with first time prescribed antihypertensive treatment. Around one in ten patients had diabetes, with a lower prevalence in women than men (8.0 vs 11.1%, P < 0.01). The most preferred drug class was angiotensin converting enzyme inhibitors (36.2%), although substantially less common in women than in men (30.5 vs 43.1%; P < 0.001). However, diuretics were more common in women (32.4 vs. 19.7%; P < 0.001), while we observed no differences between women and men in the prescriptions of angiotensin receptor blockers (3.6 vs 4.3%), beta blockers (21.8 vs 19.5%), calcium channel blockers (7.0 vs 8.0%), fixed combination therapy (1.6 vs 2.2%), and those with more than one antihypertensive drug prescription (3.1 vs 3.2%). Furthermore, there were less diabetic women than men with a prescription of an angiotensin converting enzyme inhibitor (60.2 vs 73.9%, < 0.01). Conclusions: In conclusion, angiotensin converting enzyme inhibitors is the most preferred initial antihypertensive drug class in primary care, indicating a high concordance with contemporary guidelines.

PP.27.04] BLOOD PRESSURE CONTROL IN RELATION TO THE SEX OF THE PATIENT AND THE PHYSICIAN

Objective: Earlier studies have proposed that the sex of the patient and the physician may influence if target blood pressure is reached. We investigated the associations between the sex of the patient and the physician, and achieved target blood pressure in a large unselected cohort of hypertensive patients.Design and method: This cross-sectional cohort study in the Swedish primary Care Cardiovascular Database (SPCCD) includes 16 248 patients with hypertension treated in primary health care in Stockholm in 2006–2008. The three last blood pressure measurements during the time period was analyzed and the patients were grouped female/male with all female physician visits, all male physician visits, and visits including both female and male physician visits (mixed physicians). The blood pressure measurement of the last visit was used for analysis and was <140/90 mmHg. The regression model and odds ratio for achieved target blood pressure was adjusted for age, diabetes mellitus, and cardiovascular comorbidities. Results: In 15 465 patients (8994 female and 6471 male) the sex of the physician was known. Female patients were older and had less diabetes mellitus, ischemic heart disease, and cerebrovascular disease than males (table). Target blood pressure was achieved in 36.9% of the patients visiting male physicians, 33.5% of the patients visiting female physicians, and 31.6% of the patients visiting mixed physicians (p < 0.0001 for all difference between groups). Male patients visiting a female, compared to a male physician, had a lower likelihood of reaching target blood pressure. Male patients visiting a male physician, compared to mixed physicians visits, had a higher likelihood of reaching target blood pressure (figure). In female patients the sex of the physician and the probability of reaching target blood pressure were not associated. Conclusions: The probability of reaching target blood pressure was associated with the sex of the physician in male but not in female hypertensive patients. Best results were observed in male patients with male physicians while the worst results were seen with mixed physicians.

OP.7A.04] ANTIHYPERTENSIVE DRUGS AND THE RISK OF FEMUR FRACTURE IN HYPERTENSIVE PATIENTS IN SWEDISH PRIMARY HEALTH CARE. RESULTS FROM THE SWEDISH PRIMARY CARE CARDIOVASCULAR DATABASE (SPCCD)

Objective: Hypertension and osteoporosis are major public health problems that often coexist in the aging population. This study aimed to examine the associations between exposure to different antihypertensive drug classes and the risk of femur fracture in hypertensive men and women in Swedish primary health care. Design and method: This retrospective cohort study includes 63591 individuals, 50 years and older, diagnosed with hypertension during 2001–2008 in the Swedish Primary Care Cardiovascular Database (SPCCD). All patients were followed 1 Jan 2006 (or the date of their first diagnosis of hypertension if that date came later) until they had their first femur fracture, died, or reached the end of the database on 31 December 2012, whichever came first. Cox proportional hazards models were used to calculate the relative risk of femur fracture across types of antihypertensive medications. Analyses were adjusted for age, sex, comorbidity, medications and socioeconomic factors. Results: A total of 2737 femur fractures were observed during follow-up. Current use of thiazides was associated with a reduced risk of femur fracture (HR 0.83; 95% CI 0.74–0.93), as well as use of fixed drug combinations containing a thiazide (ACE-inhibitors + thiazide or angiotensin-receptor blocker + thiazide) (HR 0.67; 95% CI 0.56–0.80). Current use of loop-diuretics was associated with an increased risk of femur fracture (HR 1.23; 95% CI 1.09–1.38). No significant associations were found between femur fracture and current exposure to beta-blockers, alfa-blockers, aldosterone-receptor blockers, ACE-inhibitors, angiotensin-receptor blockers or calcium-channel blockers. Conclusions: In this large observational study of hypertensive patients, we could identify a protective effect on femur fracture risk in users of thiazide diuretics or combination pills containing a thiazide, whereas use of loop-diuretics was associated with an increased risk. Exposure to any other antihypertensive agent was associated with neither a decrease nor increase in fracture risk. In conclusion, the risk of femur fracture appear to differ across users of different antihypertensive agents, a knowledge that could have practical applications in primary health care to prevent adverse outcomes from both hypertension and osteoporosis in the aging population.