R. J. G. Peters

Approaches for non-invasive assessment of endothelial function: focus on peripheral arterial tonometry

The arterial endothelium is a complex organ that modulates vascular tone by release of various substances to control perfusion. Endothelial function reflects vascular ageing and health. Already at the earliest stages of atherosclerosis the delicate balance between arterial constriction and relaxation is disturbed. Therefore, non-invasive assessment of endothelial function is a means to identify patients at increased cardiovascular risk, even at levels of disease that cannot be identified with classical imaging techniques that depict arterial wall and/or lumen or with functional assessment of ischaemia. Currently, there is an increasing interest in the early recognition of endothelial dysfunction to streamline and optimise preventive therapeutic measures. In this article, several methods for the assessment of endothelial function are briefly reviewed. In particular, we discuss the fast bed-side assessment of endothelial function by the reactive hyperaemia peripheral arterial tonometry (RH-PAT) method.

RESPONSE study: Randomised Evaluation of Secondary Prevention by Outpatient Nurse SpEcialists: Study design, objectives and expected results.

Background. Patients with coronary artery disease are at high risk of coronary events and death, but effective secondary prevention can reduce this risk. There is a gap between guidelines on secondary prevention and the implementation of these measures, which could potentially be reduced by nurse led prevention clinics (NLPC).Objectives. The aim of the current study is to quantify the impact of NLPC on the risk of cardiovascular events in patients with established coronary artery disease.Methods. A randomised, multicentre clinical trial of NLPC in addition to usual care or usual care alone in post-acute coronary syndrome patients. (Neth Heart J 2009;17:322–8.)

Improving guideline adherence for cardiac rehabilitation in the Netherlands

BackgroundIn 2004, the Netherlands Society of Cardiology released the current guideline on cardiac rehabilitation. Given its complexity and the involvement of various healthcare disciplines, it was supplemented with a clinical algorithm, serving to facilitate its implementation in daily practice. Although the algorithm was shown to be effective for improving guideline adherence, several shortcomings and deficiencies were revealed. Based on these findings, the clinical algorithm has now been updated. This article describes the process and the changes that were made.MethodsThe revision consisted of three phases. First, the reliability of the measurement instruments included in the 2004 Clinical Algorithm was investigated by evaluating between-centre variations of the baseline assessment data. Second, based on the available evidence, a multidisciplinary expert advisory panel selected items needing revision and provided specific recommendations. Third, a guideline development group decided which revisions were finally included, also taking practical considerations into account.ResultsA total of nine items were revised: three because of new scientific insights and six because of the need for more objective measurement instruments. In all revised items, subjective assessment methods were replaced by more objective assessment tools (e.g. symptom-limited exercise instead of clinical judgement). In addition, four new key items were added: screening for anxiety/depression, stress, cardiovascular risk profile and alcohol consumption.ConclusionBased on previously determined shortcomings, the Clinical Algorithm for Cardiac Rehabilitation was thoroughly revised mainly by incorporating more objective assessment methods and by adding several new key areas.

Ethnic disparities in the association of impaired fasting glucose with the 10-year cumulative incidence of type 2 diabetes

AIMSnEvidence of ethnic disparities in the conversion of prediabetes to type 2 diabetes is scarce. We studied the association of impaired fasting glucose (IFG) and fasting plasma glucose (FPG) with the 10-year cumulative incidence of type 2 diabetes in three ethnic groups.nnnMETHODSnWe analyzed data for 90 South-Asian Surinamese, 190 African-Surinamese, and 176 ethnic Dutch that were collected in the periods 2001-2003 and 2011-2012. We excluded those with type 2 diabetes or missing FPG data. We defined baseline IFG as FPG of 5.7-6.9 mmol/L. We defined type 2 diabetes at follow-up as FPG ≥ 7.0 mmol/L, HbA1c ≥ 48 mmol/mol (6.5%), or self-reported type 2 diabetes.nnnRESULTSn10-Year cumulative incidences of type 2 diabetes were: South-Asian Surinamese, 18.9%; African-Surinamese, 13.7%; ethnic Dutch, 4.5% (p<0.05). The adjusted association of baseline IFG and FPG with the 10-year cumulative incidence of type 2 diabetes was stronger for South-Asian Surinamese than for African-Surinamese and ethnic Dutch. The IFG (compared to normoglycaemia) ORs were 11.1 [3.0-40.8] for South-Asian Surinamese, 5.1 [2.0-13.3] for African-Surinamese, and 2.2 [0.5-10.1] for ethnic Dutch.nnnCONCLUSIONSnThe 10-year cumulative incidence of type 2 diabetes was higher and associations with baseline IFG and FPG were stronger among South-Asian Surinamese and African-Surinamese than among ethnic Dutch. Our findings confirm the high risk of type 2 diabetes in South-Asians and suggest more rapid conversion in populations of South-Asian origin and (to a lesser extent) African origin than European origin.

Cardiovascular disease risk and secondary prevention of cardiovascular disease among patients with low health literacy

ObjectiveTo explore the association between health literacy and the risk of cardiovascular disease (CVD), and to assess the differential effects by health literacy level of axa0nurse-coordinated secondary prevention program (NCPP) in patients with coronary artery disease (CAD).MethodsData were collected in two medical centres participating in the RESPONSE trial (Randomised Evaluation of Secondary Prevention by Outpatient Nurse SpEcialists). CVD risk profiles were assessed at baseline and 12-month follow-up using the Systematic Coronary Risk Evaluation (SCORE). Health literacy was assessed by the short Rapid Estimate of Adult Literacy in Medicine (REALM-D) and the Newest Vital Sign (NVS-D); self-reported health literacy was evaluated by the Set of Brief Screening Questions (SBSQ-D).ResultsAmong 201 CAD patients, 18% exhibited reading difficulties, 52% had difficulty understanding and applying written information, and 5% scored low on self-reported health literacy. Patients with low NVS-D scores had axa0higher CVD risk [mean SCORExa05.2 (SDxa04.8) versusxa03.3 (SDxa04.1), pxa0< 0.01]. Nurse-coordinated care seemed to reduce CVD risk irrespective of health literacy levels without significant differences.ConclusionInadequate health literacy is prevalent in CAD patients in the Netherlands, and is associated with less favourable CVD risk profiles. Where many other forms of CVD prevention fail, nurse-coordinated care seems to be effective among patients with inadequate health literacy.

Nurses' perspectives on nurse-coordinated prevention programmes in secondary prevention of cardiovascular disease: a pilot survey

Background: Secondary prevention of coronary artery disease (CAD) is increasingly provided by nurse-coordinated prevention programs (NCPP). Little is known about nurses’ perspectives on these programs. Aim: To investigate nurses’ perspectives/experiences in NCPPs in acute coronary syndrome patients. Methods: Thirteen nurses from NCPPs in 11 medical centers in the RESPONSE trial completed an online survey containing 45 items evaluating 3 outcome categories: (1) conducting NCPP visits; (2) effects of NCPP interventions on risk profiles and (3) process of care. Results: Nurses felt confident in counseling/motivating patients to reduce CAD risk. Interventions targeting LDL, blood pressure and medication adherence were reported as successful, corresponding with significant improvements of these risk factors. Improving weight, smoking and physical activity was reported as less effective. Screening for anxiety/depression was suggested as an improvement. Conclusions: Nurses acknowledge the importance and effectiveness of NCPPs, and correctly identify which components of the program are the most successful. Our study provides a basis for implementation and quality improvement for NCCPs.

Ethnic disparities in estimated cardiovascular disease risk in Amsterdam, the Netherlands

BackgroundEthnic differences have been reported in cardiovascular disease (CVD) risk factors. It is still unclear which ethnic groups are most at risk for CVD when all traditional CVD risk factors are considered together as overall risk.ObjectivesTo examine ethnic differences in overall estimated CVD risk and the risk factors that contribute to these differences.DesignUsing data of the multi-ethnic HELIUS study (HEalthy LIfe in an Urban Setting) from Amsterdam, we examined whether estimated CVD risk and risk factors among those eligible for CVD risk estimation differed between participants of Dutch, South Asian Surinamese, African Surinamese, Ghanaian, Turkish and Moroccan origin. Using the Systematic COronary Risk Evaluation (SCORE) algorithm, we estimated risk of fatal CVD and risk of fatal plus non-fatal CVD. These risks were compared between ethnic groups via age-adjusted linear regression analyses.ResultsThe SCORE algorithm was applicable to 9,128 participants. Relative to the fatal CVD risk of participants of Dutch origin, South Asian Surinamese participants showed axa0higher fatal CVD risk, Ghanaian males axa0lower fatal CVD risk, and participants of other ethnic origins axa0similar fatal CVD risk. For fatal plus non-fatal CVD risk, African Surinamese and Turkish men also showed axa0higher risk. When diabetes was incorporated in the CVD risk algorithm, all but Ghanaian men showed axa0higher CVD risk relative to the participants of Dutch origin (betas ranging from 0.98–3.10%). The CVD risk factors that contribute the most to these ethnic differences varied between ethnic groups.ConclusionEthnic minority groups are at axa0greater estimated risk of fatal plus non-fatal CVD relative to the group of native Dutch. Further research is necessary to determine whether this will translate to ethnic differences in CVD incidence and, if so, whether ethnic-specific CVD prevention strategies are warranted.

Smoking cessation in European patients with coronary heart disease. Results from the EUROASPIRE IV survey: A registry from the European Society of Cardiology

OBJECTIVEnWe investigated smoking cessation rates in coronary heart disease (CHD) patients throughout Europe; current and as compared to earlier EUROASPIRE surveys, and we studied characteristics of successful quitters.nnnMETHODSnAnalyses were done on 7998 patients from the EUROASPIRE-IV survey admitted for myocardial infarction, unstable angina and coronary revascularisation. Self-reported smoking status was validated by measuring carbon monoxide in exhaled air.nnnRESULTSnThirty-one percent of the patients reported being a smoker in the month preceding hospital admission for the recruiting event, varying from 15% in centres from Finland to 57% from centres in Cyprus. Smoking rates at the interview were also highly variable, ranging from 7% to 28%. The proportion of successful quitters was relatively low in centres with a low number of pre- event smokers. Overall, successful smoking cessation was associated with increasing age (OR 1.50; 95% CI 1.09-2.06) and higher levels of education (OR 1.38; 95% CI 1.08-1.75). Successful quitters more frequently reported that they had been advised (56% vs. 47%, pu202f<u202f.001) and to attend (81% vs. 75%, pu202f<u202f.01) a cardiac rehabilitation programme.nnnCONCLUSIONnOur study shows wide variation in cessation rates in a large contemporary European survey of CHD patients. Therefore, smoking cessation rates in patients with a CHD event should be interpreted in the light of pre-event smoking prevalence, and caution is needed when comparing cessation rates across Europe. Furthermore, we found that successful quitters reported more actions to make healthy lifestyle changes, including participating in a cardiac rehabilitation programme, as compared with persistent smokers.

Ethnic differences in metabolite signatures and type 2 diabetes : a nested case-control analysis among people of South Asian, African and European origin

Accumulation of metabolites may mark or contribute to the development of type 2 diabetes mellitus (T2D), but there is a lack of data from ethnic groups at high risk. We examined sphingolipids, acylcarnitines and amino acids, and their association with T2D in a nested case–control study among 54 South Asian Surinamese, 54 African Surinamese and 44 Dutch in the Netherlands. Plasma metabolites were determined at baseline (2001–2003), and cumulative prevalence and incidence of T2D at follow-up (2011–2012). Weighted linear and logistic regression analyses were used to study associations. The mean level of most sphingolipids was lower, and amino-acid levels higher, in the Surinamese groups than among the Dutch. Surinamese individuals had higher mono- and polyunsaturated acylcarnitines and lower plasma levels of saturated acylcarnitine species than the Dutch. Several sphingolipids and amino acids were associated with T2D. Although only the shorter acylcarnitines seemed associated with prevalent T2D, we found an association of all acylcarnitines (except C0, C18 and C18:2) with incident T2D. Further analyses suggested a potentially different association of several metabolites across ethnic groups. Extension and confirmation of these findings may improve the understanding of ethnic differences and contribute to early detection of increased individual risk.

Lifestyle changes in secondary prevention of coronary heart disease: breaking the chains of unhealthy habits

The management of patients with acute coronary complications includes three components: short-term local therapy for clinically significant coronary obstructions, cardiac rehabilitation (CR) and long-term treatment of the underlying atherosclerotic process. Of these, the last mentioned appears to be the most challenging. n nThere is little question as to which factors should be addressed to inhibit progression of the disease, and guidelines on this topic are clear and consistent around the world. Changing unhealthy lifestyles may lead to reductions in the risk of mortality that are greater than the benefits of some of the acute treatments for coronary disease [1]. Unfortunately, the success of these lifestyle changes in practice is limited. In general, drug treatments and the achievement of their target values are relatively adequate [2]. However, the widely recommended healthy lifestyles are frequently not achieved. In a recent observation from 17 countries, nearly 1 in 5 individuals continued to smoke, only 1 in 3 individuals reported high levels of physical activity and 2 in 5 reported a healthy diet [3]. As these proportions are based on self reports, true numbers may in fact be lower. Thus, a large gap exists between guidelines and their implementation in reality. The causes for this discrepancy are multiple and complex. n nOn the patient’s side, it is challenging to change habits that have been in place for many decades, that are shared with their partner and with their social environment, and that are generally associated with short-term quality of life. In addition, the concept of long-term prevention is complex: the sacrifices are clear and instant whereas the rewards are uncertain and distant. Some of the lifestyle changes may be costly to the patient, such as healthy food choices and engaging in exercise. n nOn the physician’s side, the short-term treatment of coronary disease is rewarding, in medical, psychological and financial terms, whereas the management of long-term risk is less rewarding and not infrequently frustrating. In recent years, the management of secondary prevention has increasingly been transferred to paramedical personnel. Nurses, physiotherapists and dieticians now play an important role, particularly in addressing the lifestyle-related components. Nonetheless, overall results are suboptimal and new approaches are needed to promote healthy lifestyles and thus achieve better outcomes. n nThe OPTICARE study is designed to test two strategies to improve implementation of guideline-based secondary prevention, in addition to a standard program of CR, in patients with a recent coronary incident [4]. In the COACH arm, a previously explored approach of telephone coaching is added, with five contacts in the first 6xa0months after hospital discharge. Coaches are trained nurses in a single, central facility who encourage the patients to adopt healthy lifestyles and to adhere to their medication. n nIn the CAPRI arm, more group sessions are added to the regular program, pedometers are issued to provide feedback on activities and additional long-term sessions are included in the first year after hospital discharge. In this study arm, medications for low-density lipoprotein (LDL) and blood pressure control are titrated to target levels by study personnel, in collaboration with the treating physician. n nThe control group will receive CR as it is currently offered (usual care). The primary outcome of the study is an overall estimate of the 10-year risk of cardiovascular morbidity and mortality, the Systematic Coronary Risk Evaluation (SCORE) calculation. Secondary outcomes include risk factors separately and clinical events. In addition, cost-effectiveness will be analysed. n nAs outlined above, the OPTICARE study addresses a very important subject, and if completed as planned may contribute to real improvements in secondary prevention. The tested interventions are widely applicable, if proven successful. The goals of the study are ambitious and include improvements in virtually all components of secondary prevention, ranging from improved achievement of target values for LDL cholesterol and blood pressure to improved physical activity and cessation of smoking. Since self-reported outcome measures may not be reliable, the outcomes of the study at 12xa0months follow-up are measured by objective assessments, such as accelerometry and breath carbon monoxide. n nIn studies on long-term prevention, an overall quantification of risk is the preferred outcome parameter. The primary outcome of the OPTICARE study, the SCORE risk estimate, is validated only in primary prevention. For secondary prevention, no such risk function is available. In secondary prevention, the absolute SCORE estimate is not a meaningful metric. However, for comparisons among groups and between baseline and 12-month outcome, SCORE can be used as a relative measure. A similar approach was selected in the RESPONSE 1 study [5]. Another limitation of this primary outcome parameter in the OPTICARE study is that it does not reflect a number of important risk factors that are addressed in the interventions, including physical activity and healthy food choices. Any favourable change in these parameters will be missed in the SCORE function. The authors describe the study as featuring a PRospective Open, Blinded Endpoint (PROBE) design. However, this reflects only the secondary outcome parameter of clinical events, for which the study is not powered statistically. n nCost-effectiveness is an important component of the study. If improvements are achieved only at great cost, implementation into practice is not likely to occur. The time span of this analysis, of 12xa0months, is likely to lead to underestimation of cost effectiveness. If successful adoption of healthy lifestyles is indeed achieved, the benefits may, ideally, persist in the patient’s remaining lifetime and thus lead to better results at the same cost. n nIn the interventions tested in OPTICARE, personal attention by (para)medical professionals stands out as one of the most important components. A single advice given in an outpatient visit has little impact, particularly in the long term. In fact, most patients are aware of the traditional risk factors and the recommendation to improve on them hardly provides new information. Repeated personal attention from professionals, in addition to group pressure and partner support, may be required to achieve permanent changes in lifestyle. Based on similar concepts in secondary prevention in patients with coronary artery disease, the RESPONSE 2 study is currently underway in the Netherlands. In this study, external commercial parties are involved in addressing the three most important lifestyle components: overweight and obesity (Weight Watchers®), physical inactivity (Philips DirectLife® activity program) and smoking (Luchtsignaal®). In the future, combinations of the interventions described in studies such as OPTICARE and RESPONSE 2 will hopefully assist our patients in adopting a healthy lifestyle and thus prevent recurrences of their disease.