Bjørn Gjelsvik

European guidelines on cardiovascular disease prevention in clinical practice: executive summary

Guidelines and Expert Consensus Documents summarize and evaluate all currently available evidence on a particular issue with the aim to assist physicians in selecting the best management strategies for a typical patient, suffering from a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines are not substitutes for textbooks. The legal implications of medical guidelines have been discussed previously. A great number of Guidelines and Expert Consensus Documents have been issued in recent years by the European Society of Cardiology (ESC) as well as by other societies and organizations. Because of the impact on clinical practice, quality criteria for development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC Guidelines and Expert Consensus Documents can be found on the ESC web site (http://www.escardio.org/knowledge/guidelines/rules). In brief, experts in the field are selected and undertake a comprehensive review of the published evidence for management and/or prevention of a given condition. A critical evaluation of diagnostic and therapeutic procedures is performed, including assessment of the risk–benefit ratio. Estimates of expected health outcomes for larger societies are included, where data exist. The level of evidence and the strength of recommendation of particular treatment options are weighed and graded according to predefined scales, as outlined in the tables below. The experts of the writing panels have provided disclosure statements of all relationships they may have which might be perceived as real or potential sources of conflicts of interest. These disclosure forms are kept on file at the European Heart House, headquarters of the ESC. Any changes in conflict of interest that arise during the writing period must be notified to the ESC. The Task Force report was entirely …

European guidelines on cardiovascular disease prevention in clinical practice: full text. Fourth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts).

Other experts who contributed to parts of the guidelines: Edmond Walma, Tony Fitzgerald, Marie Therese Cooney, Alexandra Dudina European Society of Cardiology (ESC) Committee for Practice Guidelines (CPG): Alec Vahanian (Chairperson), John Camm, Raffaele De Caterina, Veronica Dean, Kenneth Dickstein, Christian Funck-Brentano, Gerasimos Filippatos, Irene Hellemans, Steen Dalby Kristensen, Keith McGregor, Udo Sechtem, Sigmund Silber, Michal Tendera, Petr Widimsky, Jose Luis Zamorano Document reviewers: Irene Hellemans (CPG Review Co-ordinator), Attila Altiner, Enzo Bonora, Paul N. Durrington, Robert Fagard, Simona Giampaoli, Harry Hemingway, Jan Hakansson, Sverre Erik Kjeldsen, Mogens Lytken Larsen, Giuseppe Mancia, Athanasios J. Manolis, Kristina Orth-Gomer, Terje Pedersen, Mike Rayner, Lars Ryden, Mario Sammut, Neil Schneiderman, Anton F. Stalenhoef, Lale Tokgözoglu, Olov Wiklund, Antonis Zampelas

Fourth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (Constituted by representatives of nine societies and by invited experts)

Other experts who contributed to parts of the guidelines: Edmond Walma, Schoonhoven (The Netherlands), Tony Fitzgerald, Dublin (Ireland), Marie Therese Cooney, Dublin (Ireland), Alexandra Dudina, Dublin (Ireland) European Society of Cardiology (ESC) Committee for Practice Guidelines (CPG):, Alec Vahanian (Chairperson) (France), John Camm (UK), Raffaele De Caterina (Italy), Veronica Dean (France), Kenneth Dickstein (Norway), Christian Funck-Brentano (France), Gerasimos Filippatos (Greece), Irene Hellemans (The Netherlands), Steen Dalby Kristensen (Denmark), Keith McGregor (France), Udo Sechtem (Germany), Sigmund Silber (Germany), Michal Tendera (Poland), Petr Widimsky (Czech Republic), José Luis Zamorano (Spain) Document reviewers: Irene Hellemans (CPG Review Coordinator) (The Netherlands), Attila Altiner (Germany), Enzo Bonora (Italy), Paul N. Durrington (UK), Robert Fagard (Belgium), Simona Giampaoli(Italy), Harry Hemingway (UK), Jan Hakansson (Sweden), Sverre Erik Kjeldsen (Norway), Mogens Lytken Larsen (Denmark), Giuseppe Mancia (Italy), Athanasios J. Manolis (Greece), Kristina Orth-Gomer (Sweden), Terje Pedersen (Norway), Mike Rayner (UK), Lars Ryden (Sweden), Mario Sammut (Malta), Neil Schneiderman (USA), Anton F. Stalenhoef (The Netherlands), Lale Tokgözoglu (Turkey), Olov Wiklund (Sweden), Antonis Zampelas (Greece)

Symptom prevalence during menopause and factors associated with symptoms and menopausal age. Results from the Norwegian Hordaland Women's Cohort study

OBJECTIVES To describe symptoms during the menopausal transition and age at menopause in a representative Norwegian female cohort over a ten year period, to analyze factors associated with frequency and burden of symptoms and influence on self-rated health. STUDY DESIGN 2229 women aged 40-44 years at inclusion, randomly selected from a national health survey in Hordaland County, Norway, and followed with seven postal questionnaires from 1997 throughout 2009. Data for 2002 women (90%) were eligible for analyses. RESULTS In a longitudinal analysis, 36% of the women reported daily hot flushes in one or more questionnaires, whereas 29% did not experience hot flushes at all. The prevalence of daily hot flushes increased from 2% at age 41-42 to 22% at age 53-54, decreasing to 20% at age 55-57. The odds ratio for reporting daily hot flushes vs. never/seldom for daily smokers was 1.6 (1.24-2.10). Women in the lowest education group had an OR=1.8 (1.21-2.56) for reporting daily hot flushes compared to women with a university degree. There was no relation between the symptom burden and degree of physical exercise, overall feeling of health, BMI, family income, parity or menarche age as recorded at baseline. The mean age for final menstruation period (FMP) in the cohort was 51.1 (50.9-51.3) years. Smokers had a mean age of FMP 0.9 years earlier compared to the non-smokers. CONCLUSIONS Daily smoking and educational level were independent risk factors for experiencing daily menopausal symptoms. Degree of physical exercise, BMI, parity or menarche age did not have significant influence.

Norway’s new principles for primary prevention of cardiovascular disease: age differentiated risk thresholds

Norway decided not to follow European guidelines on preventing cardiovascular disease and instead developed its own with age based thresholds. Ole Norheim and colleagues explain the rationale behind them

Type 2 diabetes in general practice in Norway 2005-2014: moderate improvements in risk factor control, but still major gaps in complication screening

Objective To assess the status of type 2 diabetes care in general practice and changes in the quality of care between 2005 and 2014, and to identify areas of diabetes care requiring improvement. Research design and methods Two cross-sectional surveys were performed that included patients with type 2 diabetes in selected areas (n=9464 in 2014, n=5463 in 2005). Quality of care was assessed based on key recommendations in national guidelines. Differences in clinical performance between 2005 and 2014 were assessed in regression models adjusting for age, sex, counties and clustering within general practices. Results Treatment targets were achieved in a higher proportion of patients in 2014 compared with 2005: hemoglobin A1c ≤7.0% (≤53 mmol/mol) in 62.8% vs 54.3%, blood pressure ≤135/80 mm Hg in 44.9% vs 36.6%, and total cholesterol ≤4.5 mmol/L in 49.9% vs 33.5% (all adjusted P≤0.001). Regarding screening procedures for microvascular complications, fewer patients had recorded an eye examination (61.0% vs 71.5%, adjusted P<0.001), whereas more patients underwent monofilament test (25.9% vs 18.7%, adjusted P<0.001). Testing for albuminuria remained low (30.3%) in 2014. A still high percentage were current smokers (22.7%). Conclusions We found moderate improvements in risk factor control for patients with type 2 diabetes in general practice during the last decade, which are similar to improvements reported in other countries. We report major gaps in the performance of recommended screening procedures to detect microvascular complications. The proportion of daily smokers remains high. We suggest incentives to promote further improvements in diabetes care in Norway.

Conflicts and dilemmas in prevention of cardiovascular disease. The new, Norwegian Guidelines—a new approach to risk management

Prevention of cardiovascular disease (CVD) has been debated for many years, between an organ-specialist perspective versus a public health view. As an illustration, the Wonca Europe Council decided in 2004 to withdraw its support to the 2003 European Guidelines. This paper discusses the main sources of disagreement, most important the levels of risk when treatment should be offered. The Norwegian Guideline for primary prevention of CVD (2009) introduced a new principle of age-differentiated risk levels. Pharmacological treatment should be offered to all persons aged 40–49 years with 10-year mortality risk ≥ 1%, all persons aged 50–59 years at ≥ 5% risk, and all persons aged 60–69 years at ≥ 10% risk. Lower thresholds for younger persons are based on the fact that life years lost, will be considerable if drugs are prescribed only for risk levels above 5%. For persons aged 60–69 years, age is the dominant risk factor and the benefits of treatment are smaller. The implications of the recommendation are discussed, both at an individual and a societal level. Compared to the European 2007 guidelines, the total sum of life years gained is about the same, but the number of patients treated is considerably lower.

Are general practitioners characteristics associated with the quality of type 2 diabetes care in general practice? Results from the Norwegian ROSA4 study from 2014

Abstract Objective: To explore the associations between general practitioners (GPs) characteristics such as gender, specialist status, country of birth and country of graduation and the quality of care for patients with type 2 diabetes (T2DM). Design: Cross-sectional survey. Setting and subjects: The 277 GPs provided care for 10082 patients with T2DM in Norway in 2014. The GPs characteristics were self-reported: 55% were male, 68% were specialists in General Practice, 82% born in Norway and 87% had graduated in Western Europe. Of patients, 81% were born in Norway and 8% in South Asia. Data regarding diabetes care were obtained from electronic medical records and manually verified. Main outcome measures: Performance of recommended screening procedures, prescribed medication and level of HbA1c, blood pressure and LDL-cholesterol stratified according to GPs characteristics, adjusted for patient and GP characteristics. Result: Female GPs, specialists, GPs born in Norway and GPs who graduated in Western Europe performed recommended procedures more frequently than their counterparts. Specialists achieved lower mean HbA1c (7.14% vs. 7.25%, p < 0.01), a larger proportion of their patients achieved good glycaemic control (HbA1c = 6.0%–7.0%) (49.1% vs. 44.4%, p = 0.018) and lower mean systolic blood pressure (133.0 mmHg vs. 134.7 mmHg, p < 0.01) compared with non-specialists. GPs who graduated in Western Europe achieved lower diastolic blood pressure than their counterparts (76.6 mmHg vs. 77.8 mmHg, p < 0.01). Conclusion: Several quality indicators for type 2 diabetes care were better if the GPs were specialists in General Practice. Key Points Research on associations between General Practitioners (GPs) characteristics and quality of care for patients with type 2 diabetes is limited. Specialists in General Practice performed recommended procedures more frequently, achieved better HbA1c and blood pressure levels than non-specialists. GPs who graduated in Western Europe performed screening procedures more frequently and achieved lower diastolic blood pressure compared with their counterparts. There were few significant differences in the quality of care between GP groups according to their gender and country of birth.

Population, general practitioner and practice characteristics are associated with screening procedures for microvascular complications in Type 2 diabetes care in Norway

To assess population, general practitioner (GP) and practice characteristics associated with the performance of microvascular screening procedures and to propose strategies to improve Type 2 diabetes care.

Nye retningslinjer for forebygging av hjerte- og karsykdom

E-mail: tor.ole.klemsdal@vikenfiber.no Tor Ole Klemsdal (born 1958) dr.med. is a specialist in internal medicine and in cardiology, and senior consultant and head of section at Oslo University Hospital. He was contracted by the Norwegian Directorate of Health to work on these and other guidelines. The author has completed the ICMJE form and reports the following conflicts of interest: He has received personal speaker fees from MSD Norway, Astra Zeneca, BMS-Squibb Norway, Novartis Norway and Sanofi-Aventis Norway.