Einar Husebye

The role of medical and psychosocial factors for unfavourable coronary risk factor control

Abstract Objectives. This project aims to identify socio-demographic, medical and psychosocial factors (study factors) associated with coronary risk control and prognosis, and to test their impact in a representative sample of coronary heart disease (CHD) patients. Design. The first phase includes a cross-sectional study designed to explore the association between the study factors and coronary risk factor control in CHD patients. Data from hospital records, a questionnaire, clinical examination and blood samples were collected. The independent effects of study factors on subsequent coronary events will be explored prospectively by controlling for baseline coronary risk factors. In the second phase, we will test the effect of tailored interventions to modify the study factors associated with unfavourable risk profile in phase I. Results. In all 1366 patients (21% women), aged 18-80 years with a coronary event on average 17 (2-38) months prior to study participation were identified (83% participation rate). Of the 239 patients who refused participation, 229 patients consented to analysis of hospital record data (non- participants). Conclusions. If the study variables contribute to CHD risk factors and prognosis, the present project may be important for the development of prevention programs by tailoring these to the patients perceived needs and behaviour profiles. Trial registration: ClinicalTrials.gov identifier: NCT02309255.

Medical and psychosocial factors and unfavourable low-density lipoprotein cholesterol control in coronary patients:

Objective Understanding the determinants of low-density lipoprotein cholesterol (LDL-C) control constitutes the basis of modelling interventions for optimal lipid control and prognosis. We aim to identify medical and psychosocial (study) factors associated with unfavourable LDL-C control in coronary patients. Methods A cross-sectional explorative study used logistic and linear regression analysis to investigate the association between study factors and LDL-C in 1095 patients, hospitalized with myocardial infarction and/or a coronary revascularization procedure. Data were collected from hospital records, a comprehensive self-report questionnaire, clinical examination and blood samples after 2–36 months follow-up. Results Fifty-seven per cent did not reach the LDL-C target of 1.8u2009mmol/l at follow-up. Low socioeconomic status and psychosocial factors were not associated with failure to reach the LDL-C target. Statin specific side-effects (odds ratio 3.23), low statin adherence (odds ratio 3.07), coronary artery by-pass graft operation as index treatment (odds ratio 1.95),u2009≥u20091 coronary event prior to the index event (odds ratio 1.81), female gender (odds ratio 1.80), moderate- or low-intensity statin therapy (odds ratio 1.62) and eating fishu2009<u20093 times/week (odds ratio 1.56) were statistically significantly associated with failure to reach the LDL-C target, in adjusted analyses. Only side-effects (standardized β 0.180), low statin adherence (β 0.209) and moderate- or low-intensity statin therapy (β 0.228) were associated with LDL-C in continuous analyses. Conclusions Statin specific side-effects, low statin adherence and moderate- or low-intensity statin therapy were the major factors associated with unfavourable LDL-C control. Interventions to improve LDL-C should ensure adherence and prescription of sufficiently potent statins, and address side-effects appropriately.

The prevalence and predictors of elevated C-reactive protein after a coronary heart disease event

Objective An interleukin-beta antagonist reduces the risk of subsequent cardiovascular events in coronary patients with high-sensitivity C-reactive protein (hs-CRP) ≥2u2009mg/L. It remains to be defined how large the coronary population at inflammatory risk is, and what the predictors of elevated risk are. Methods A cross-sectional study investigated the proportion of patients with elevated hs-CRP (i.e. ≥2u2009mg/L) and the respective demographic and clinical predictors in 971 patients without concomitant inflammatory diseases who had been hospitalized with myocardial infarction (80%) and/or a revascularization procedure. Data were collected from hospital records, a self-report questionnaire and a clinical examination with blood samples. Results After 2–36 month follow-up, 39% (nu2009=u2009378) had hs-CRPu2009≥u20092u2009mg/L, among whom 64% (nu2009=u2009243) had low-density lipoprotein cholesterol (LDL-C) ≥1.8u2009mmol/L and 47% (nu2009=u2009176) used a low-intensity statin regime. Only 24% had both LDL and hs-CRP at target range, 27% had elevation of both, whereas 12% had hs-CRPu2009≥u20092u2009mg/L and LDL-Cu2009<u20091.8u2009mmol/L. Somatic comorbidity (odds ratio (OR) 1.3/1.0 point on the Charlson score), ≥1 previous coronary event (OR 2.4), smoking (OR 2.2), higher body mass index (OR 1.2/1.0u2009kg/m2), high LDL-C (OR 1.4/1.0u2009mmol/L) and higher anxiety scores (OR 1.1/1.0 point increase on the Hospital Anxiety and Depression Scale-Anxiety subscale score) were significantly associated with hs-CRP ≥2u2009mg/L in adjusted analyses. Conclusions Elevated hs-CRP was frequently observed after a coronary event and associated with unfavourable LDL-C and unhealthy lifestyles and psychosocial distress. Intensified statin therapy and strategies to target these modifiable factors are the encouraged first steps to reduce inflammation and improve LDL-C in these patients.

Optimal blood pressure control after coronary events : the challenge remains

We identified sociodemographic, medical, and psychosocial factors associated with unfavorable blood pressure (BP) control in 1012 patients, hospitalized with myocardial infarction and/or a coronary revascularization procedure. This cross-sectional study collected data from hospital records, a comprehensive self-report questionnaire, clinical examination, and blood samples after 2-36 (mean 17) months follow-up. Forty-six percent had unfavorable BP control (≥140/90 [80 in diabetics] mm Hg) at follow-up. Low socioeconomic status and psychosocial factors did not predict unfavorable BP control. Patients with unfavorable BP used on average 1.9 (standard deviation 1.1) BP-lowering drugs at hospital discharge, and the proportion of patients treated with angiotensin inhibitors and beta-blockers decreased significantly (Pxa0<xa0.001) from discharge to follow-up. Diabetes (odds ratio [OR] 2.4), higher body mass index (OR 1.05 per 1.0xa0kg/m2), and older age (OR 1.04 per year) were significantly associated with unfavorable BP control in adjusted analyses. Only age (standardized beta [β] 0.24) and body mass index (β 0.07) were associated with systolic BP in linear analyses. We conclude that BP control was insufficient after coronary events and associated with obesity and diabetes. Prescription of BP-lowering drugs in hypertensive patients seems suboptimal. Overweight and intensified drug treatment thus emerge as the major factors to target to improve BP control.

Medical and sociodemographic factors predict persistent smoking after coronary events

BackgroundUnderstanding the determinants of persistent smoking after a coronary event constitutes the basis of modelling interventions of smoking cessation in secondary prevention programs. We aim to identify the potentially modifiable medical, sociodemographic and psychosocial factors, comprising the study factors, associated with unfavourable risk factor control after CHD events.MethodsA cross-sectional explorative study used logistic regression analysis to investigate the association between study factors and smoking status in 1083 patients hospitalized with myocardial infarction and/or coronary revascularization. Hospital record data, a self-report questionnaire, clinical examination and blood samples were applied.ResultsAt the index hospitalization, 390 patients were smoking and at follow-up after 2–36xa0months 167 (43%) of these had quit, while 230 reported persistent smoking. In adjusted analyses, unemployed or disability benefits (Odds ratio (OR) 4.1), low education (OR 3.5), longer smoking duration (OR 2.3) and not having ST-elevation myocardial infarction (STEMI) as index event (OR 2.3) were significantly associated with persistent smoking. Psychosocial factors at follow-up were not associated with persistent smoking. Smokers reported high motivation for cessation, with 68% wanting help to quit. Only 42% had been offered nicotine replacement therapy or other cessation aids. Smokers rated use of tobacco as the most important cause of their coronary disease (6.8 on a 1–10 Likert scale).ConclusionsLow socioeconomic status, prior duration of smoking, and not having STEMI as index event were associated with persisting smoking. Persistent smokers in this study seem to have an acceptable risk perception and were motivated to cease smoking, but needed assistance through cessation programs including prescription of pharmacological aids.Trial registrationRegistered at ClinicalTrials.gov: NCT02309255, registered retrospectively.

Unfavourable risk factor control after coronary events in routine clinical practice

BackgroundRisk factor control after a coronary event in a recent European multi-centre study was inadequate. Patient selection from academic centres and low participation rate, however, may underscore failing risk factor control in routine clinical practice. Improved understanding of the patient factors that influence risk factor control is needed to improve secondary preventive strategies. The objective of the present paper was to determine control of the major risk factors in a coronary population from routine clinical practice, and how risk factor control was influenced by the study factors age, gender, number of coronary events, and time since the index event.MethodsA cross-sectional study determined risk factor control and its association with study factors in 1127 patients (83% participated) aged 18-80 years with acute myocardial infarction and/or revascularization identified from medical records. Study data were collected from a self-report questionnaire, clinical examination, and blood samples after 2-36 months (median 16) follow-up.ResultsTwenty-one percent were current smokers at follow-up. Of those smoking at the index event 56% continued smoking. Obesity was found in 34%, and 60% were physically inactive. Although 93% were taking blood-pressure lowering agents and statins, 46% were still hypertensive and 57% had LDL cholesterol >1.8xa0mmol/L at follow-up. Suboptimal control of diabetes was found in 59%. The patients failed on average to control three of the six major risk factors, and patients with >1 coronary events (pu2009<u20090.001) showed the poorest overall control. A linear increase in smoking (pu2009<u20090.01) and obesity (pu2009<u20090.05) with increasing time since the event was observed.ConclusionsThe majority of coronary patients in a representative Norwegian population did not achieve risk factor control, and the poorest overall control was found in patients with several coronary events. New strategies for secondary prevention are clearly needed to improve risk factor control. Even modest advances will provide major health benefits.Trial registrationRegistered at ClinicalTrials.gov (ID NCT02309255).

Patient characteristics and risk factors of participants and non-participants in the NOR-COR study

Abstract Objectives. We aim to compare patient characteristics and coronary risk factors among participants and non-participants in a survey of CHD patients. Methods. A cross-sectional study explored characteristics and risk factors in patients hospitalized for acute myocardial infarction and/or revascularization. Study data collected from hospital medical records were compared between participants (nu2009=u20091127, 83%) and non-participants (nu2009=u2009229, 16%), who did not consent to participation in the clinical study. Results. Non-participants showed statistically higher prevalence of women (28% versus 21%), ethnic minorities (6% versus 3%), patients living alone (26% versus 19%), depression (19% versus 6%), anxiety (9% versus 3%), hypertension (54% versus 43%) and diabetes (24% versus 17%). Significantly higher multi-adjusted odds ratios were found for Charlson comorbidity index 3.4 (95% confidence interval (CI), 2.8, 4.3) and depression 14.5 (4.4, 121.5) in non-participants. Conclusions. Non-participants do have higher prevalence of important coronary risk factors compared to participants, and risk factor control may thus be overestimated in available prevention studies. Patients with somatic comorbidity and depression appear to be at particular risk of non-participation in the present study. New strategies accounting for the causes of nonadherence are important to improve secondary prevention in CHD.

The follow-up after myocardial infarction – is it good enough?

E-mail: johmun@vestreviken.no John Munkhaugen (born 1983) is a junior consultant in cardiology and a postdoctoral researcher at the Department of Medicine, Drammen Hospital and the Department of Behavioural Sciences in Medicine, University of Oslo. He is project manager for the NOR-COR study. The author has completed the ICMJE form and declares no conflicts of interest. He receives research funding from the Norwegian Health Association.

Managing patients with prediabetes and type 2 diabetes after coronary events: individual tailoring needed - a cross-sectional study

BackgroundUnderstanding the determinants associated with prediabetes and type 2 diabetes in coronary patients may help to individualize treatment and modelling interventions. We sought to identify sociodemographic, medical and psychosocial factors associated with normal blood glucose (HbA1c <u20095.7%), prediabetes (HbA1c 5.7–6.4%), and type 2 diabetes.MethodsA cross-sectional explorative study applied regression analyses to investigate the factors associated with glycaemic status and control (HbA1c level) in 1083 patients with myocardial infarction and/or a coronary revascularization procedure. Data were collected from hospital records at the index event and from a self-report questionnaire and clinical examination with blood samples at 2–36xa0months follow-up.ResultsIn all, 23% had type 2 diabetes, 44% had prediabetes, and 33% had normal blood glucose at follow-up. In adjusted analyses, type 2 diabetes was associated with larger waist circumference (Odds Ratio 1.03 per 1.0xa0cm, pu2009=u20090.001), hypertension (Odds Ratio 2.7, pu2009<u20090.001), lower high-density lipoprotein cholesterol (Odds Ratio 0.3 per1.0xa0mmol/L, pu2009=u20090.002) and insomnia (Odds Ratio 2.0, pu2009=u20090.002). In adjusted analyses, prediabetes was associated with smoking (Odds Ratio 3.3, pu2009=u20090.001), hypertension (Odds Ratio 1.5, pu2009=u20090.03), and non-participation in cardiac rehabilitation (Odds Ratio 1.7, pu2009=u20090.003). In patients with type 2 diabetes, a higher HbA1c level was associated with ethnic minority background (standardized beta [β] 0.19, pu2009=u20090.005) and low drug adherence (β 0.17, pu2009=u20090.01). In patients with prediabetes or normal blood glucose, a higher HbA1c was associated with larger waist circumference (β 0.13, pu2009<u20090.001), smoking (β 0.18, pu2009<u20090.001), hypertension (β 0.08, pu2009=u20090.04), older age (β 0.16, pu2009<u20090.001), and non-participation in cardiac rehabilitation (β 0.11, pu2009=u20090.005).ConclusionsAlong with obesity and hypertension, insomnia and low drug adherence were the major modifiable factors associated with type 2 diabetes, whereas smoking and non-participation in cardiac rehabilitation were the factors associated with prediabetes. Further research on the effect of individual tailoring, addressing the reported significant predictors of failure, is needed to improve glycaemic control.Trial registrationRetrospectively registered at ClinicalTrials.gov: NCT02309255, December 5th 2014.

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BackgroundRisk factor control after a coronary event in a recent European multi-centre study was inadequate. Patient selection from academic centres and low participation rate, however, may underscore failing risk factor control in routine clinical practice. Improved understanding of the patient factors that influence risk factor control is needed to improve secondary preventive strategies. The objective of the present paper was to determine control of the major risk factors in a coronary population from routine clinical practice, and how risk factor control was influenced by the study factors age, gender, number of coronary events, and time since the index event.MethodsA cross-sectional study determined risk factor control and its association with study factors in 1127 patients (83% participated) aged 18-80 years with acute myocardial infarction and/or revascularization identified from medical records. Study data were collected from a self-report questionnaire, clinical examination, and blood samples after 2-36 months (median 16) follow-up.ResultsTwenty-one percent were current smokers at follow-up. Of those smoking at the index event 56% continued smoking. Obesity was found in 34%, and 60% were physically inactive. Although 93% were taking blood-pressure lowering agents and statins, 46% were still hypertensive and 57% had LDL cholesterol >1.8xa0mmol/L at follow-up. Suboptimal control of diabetes was found in 59%. The patients failed on average to control three of the six major risk factors, and patients with >1 coronary events (pu2009<u20090.001) showed the poorest overall control. A linear increase in smoking (pu2009<u20090.01) and obesity (pu2009<u20090.05) with increasing time since the event was observed.ConclusionsThe majority of coronary patients in a representative Norwegian population did not achieve risk factor control, and the poorest overall control was found in patients with several coronary events. New strategies for secondary prevention are clearly needed to improve risk factor control. Even modest advances will provide major health benefits.Trial registrationRegistered at ClinicalTrials.gov (ID NCT02309255).