Viveca Gyberg

EUROASPIRE IV : a European Society of Cardiology survey on the lifestyle, risk factor and therapeutic management of coronary patients from 24 European countries

Aims To determine whether the Joint European Societies guidelines on cardiovascular prevention are being followed in everyday clinical practice of secondary prevention and to describe the lifestyle, risk factor and therapeutic management of coronary patients across Europe. Methods and results EUROASPIRE IV was a cross-sectional study undertaken at 78 centres from 24 European countries. Patients <80 years with coronary disease who had coronary artery bypass graft, percutaneous coronary intervention or an acute coronary syndrome were identified from hospital records and interviewed and examined ≥ 6 months later. A total of 16,426 medical records were reviewed and 7998 patients (24.4% females) interviewed. At interview, 16.0% of patients smoked cigarettes, and 48.6% of those smoking at the time of the event were persistent smokers. Little or no physical activity was reported by 59.9%; 37.6% were obese (BMI ≥ 30 kg/m2) and 58.2% centrally obese (waist circumference ≥ 102 cm in men or ≥88 cm in women); 42.7% had blood pressure ≥ 140/90 mmHg (≥140/80 in people with diabetes); 80.5% had low-density lipoprotein cholesterol ≥ 1.8 mmol/l and 26.8% reported having diabetes. Cardioprotective medication was: anti-platelets 93.8%; beta-blockers 82.6%; angiotensin-converting enzyme inhibitors/angiotensin receptor blockers 75.1%; and statins 85.7%. Of the patients 50.7% were advised to participate in a cardiac rehabilitation programme and 81.3% of those advised attended at least one-half of the sessions. Conclusion A large majority of coronary patients do not achieve the guideline standards for secondary prevention with high prevalences of persistent smoking, unhealthy diets, physical inactivity and consequently most patients are overweight or obese with a high prevalence of diabetes. Risk factor control is inadequate despite high reported use of medications and there are large variations in secondary prevention practice between centres. Less than one-half of the coronary patients access cardiac prevention and rehabilitation programmes. All coronary and vascular patients require a modern preventive cardiology programme, appropriately adapted to medical and cultural settings in each country, to achieve healthier lifestyles, better risk factor control and adherence with cardioprotective medications.

Time Trends in Lifestyle, Risk Factor Control, and Use of Evidence-Based Medications in Patients With Coronary Heart Disease in Europe: Results From 3 EUROASPIRE Surveys, 1999-2013.

BACKGROUND The EUROASPIRE (European Action on Secondary and Primary Prevention by Intervention to Reduce Events) cross-sectional surveys describe time trends in lifestyle and risk factor control among coronary patients between 1999 and 2013 in Belgium, Czech Republic, Finland, France, Ireland, the Netherlands, Poland, Slovenia, and the United Kingdom as part of the EuroObservational Research Programme under the auspices of European Society of Cardiology. OBJECTIVES This study sought to describe time trends in lifestyle, risk factor control, and the use of evidence-based medication in coronary patients across Europe. METHODS The EUROASPIRE II (1999 to 2000), III (2006 to 2007), and IV (2012 to 13) surveys were conducted in the same geographical areas and selected hospitals in each country. Consecutive patients (≤70 years) after coronary artery bypass graft, percutaneous coronary intervention, or an acute coronary syndrome identified from hospital records were interviewed and examined ≥6 months later with standardized methods. RESULTS Of 12,775 identified coronary patients, 8,456 (66.2%) were interviewed. Proportion of current smokers was similar across the 3 surveys. Prevalence of obesity increased by 7%. The prevalence of raised blood pressure (≥140/90 mm Hg or ≥140/80 mm Hg with diabetes) dropped by 8% from EUROASPIRE III to IV, and therapeutic control of blood pressure improved with 55% of patients below target in IV. The prevalence of low-density lipoprotein cholesterol ≥2.5 mmol/l decreased by 44%. In EUROASPIRE IV, 75% were above the target low-density lipoprotein cholesterol <1.8 mmol/l. The prevalence of self-reported diabetes increased by 9%. The use of evidence-based medications increased between the EUROASPIRE II and III surveys, but did not change between the III and IV surveys. CONCLUSIONS Lifestyle habits have deteriorated over time with increases in obesity, central obesity, and diabetes and stagnating rates of persistent smoking. Although blood pressure and lipid management improved, they are still not optimally controlled and the use of evidence-based medications appears to have stalled apart from the increased use of high-intensity statins. These results underline the importance of offering coronary patients access to modern preventive cardiology programs.

Does pharmacologic treatment in patients with established coronary artery disease and diabetes fulfil guideline recommended targets? A report from the EUROASPIRE III cross-sectional study.

Purpose The aim was to investigate the use of cardioprotective drug therapies (aspirin or other antiplatelet agents, β-blockade, renin-angiotensin-aldosterone-system-blockade (RAAS-blockade) and statins) and treatment targets achieved in a large cohort of patients with established coronary artery disease and diabetes across Europe. Methods and results EUROASPIRE III is an observational cross-sectional study of stable coronary artery disease patients aged 18–80 years from 76 centres in 22 European countries conducted in 2006–2007. The glycaemic status (prevalent, incident or no diabetes), the guideline treatment targets achieved and the use of pharmacotherapies were assessed at one visit 6-36 months after the index event. Of all 6588 patients investigated (women 25%), 4295 (65%) had no diabetes, 752 (11%) had incident diabetes and 1541 (23%) had prevalent diabetes. All four drugs were used in 44% of the patients with no diabetes, 51% with incident diabetes and 50% with prevalent diabetes respectively. Individual prescriptions for patients with no, incident and prevalent diabetes were respectively: aspirin or other antiplatelet agents 91, 93, and 91%; β-blockers: 81, 84, and 79%; RAAS-blockers: 77, 76, and 68%; statins: 80, 80, and 79%. The proportion of patients with coronary artery disease and prevalent diabetes reaching the treatment targets were 20% for blood pressure, 53% for low density lipoprotein cholesterol (LDL-cholesterol) and 22% for haemoglobin A1c (HbA1c). Conclusion This European study demonstrates a low use of cardioprotective drug therapies among patients with a combination of coronary artery disease and diabetes, which will be contributing to the poor achievement of risk factor treatment targets for cardiovascular prevention.

The prognostic value of fasting plasma glucose, two-hour postload glucose, and HbA1c in patients with coronary artery disease : a report from EUROASPIRE IV : a survey from the European Society of Cardiology

OBJECTIVE Three tests are recommended for identifying dysglycemia: fasting glucose (FPG), 2-h postload glucose (2h-PG) from an oral glucose tolerance test (OGTT), and glycated hemoglobin A1c (HbA1c). This study explored the prognostic value of these screening tests in patients with coronary artery disease (CAD). RESEARCH DESIGN AND METHODS FPG, 2h-PG, and HbA1c were used to screen 4,004 CAD patients without a history of diabetes (age 18–80 years) for dysglycemia. The prognostic value of these tests was studied after 2 years of follow-up. The primary end point included cardiovascular mortality, nonfatal myocardial infarction, stroke, or hospitalization for heart failure and a secondary end point of incident diabetes. RESULTS Complete information including all three glycemic parameters was available in 3,775 patients (94.3%), of whom 246 (6.5%) experienced the primary end point. Neither FPG nor HbA1c predicted the primary outcome, whereas the 2h-PG, dichotomized as <7.8 vs. ≥7.8 mmol/L, was a significant predictor (hazard ratio 1.38, 95% CI 1.07–1.78; P = 0.01). During follow-up, diabetes developed in 78 of the 2,609 patients (3.0%) without diabetes at baseline. An FPG between 6.1 and 6.9 mmol/L did not predict incident diabetes, whereas HbA1c 5.7–6.5% and 2h-PG 7.8–11.0 mmol/L were both significant independent predictors. CONCLUSIONS The 2h-PG, in contrast to FPG and HbA1c, provides significant prognostic information regarding cardiovascular events in patients with CAD. Furthermore, elevated 2h-PG and HbA1c are significant prognostic indicators of an increased risk of incident diabetes.

Copeptin in patients with acute myocardial infarction and newly detected glucose abnormalities – A marker of increased stress susceptibility? A report from the Glucose in Acute Myocardial Infarction cohort:

Objective: To characterize copeptin levels and to explore its prognostic importance in patients with acute myocardial infarction with newly detected glucose abnormalities. Methods: Copeptin was measured in 166 patients with acute myocardial infarction without known diabetes and in 168 age- and gender-matched controls. Participants were classified as having normal glucose tolerance or abnormal glucose tolerance (impaired glucose tolerance + type 2 diabetes mellitus) by oral glucose tolerance test. Study participants were followed over a decade for major cardiovascular event (acute myocardial infarction/stroke/congestive heart failure/cardiovascular death), cardiovascular and total death. Results: Median copeptin level was higher in patients (10.5 pmol/L) than controls (5.9 pmol/L; p < 0.01). Patients with abnormal glucose tolerance had higher copeptin (12.2 pmol/L) than those with normal glucose tolerance (7.9 pmol/L; p < 0.01) but levels of copeptin did not differ in controls with abnormal glucose tolerance or normal glucose tolerance. Copeptin predicted major cardiovascular events [n = 64; hazard ratio = 1.15 (1.01–1.32; p = 0.04)], cardiovascular mortality [n = 29; hazard ratio = 1.24 (1.06–1.46; p = 0.01)] and total death [n = 51; hazard ratio = 1.21 (1.05–1.40; p = 0.01)] in unadjusted Cox regression analyses in the patient cohort. In controls, copeptin predicted major cardiovascular events [n = 26; hazard ratio = 1.17 (1.01–1.36; p = 0.03)]. Conclusion: Copeptin levels are highest among acute myocardial infarction patients with glucose disturbances and predict an adverse prognosis in unadjusted analyses. These findings imply that raised copeptin reflects stress rather than acting as a pathogenic factor for glucose abnormalities.

Measuring risk online—Feasibility of using FINDRISC in an online workplace survey

AIMS With the globally increasing prevalence of diabetes and the knowledge on how to prevent the disease there is a high demand for an effective way of identifying people at risk. The hypothesis behind this investigation was that incorporation of the FINnish Diabetes Risk SCore (FINDRISC) questionnaire in a regular workplace survey would be a feasible way to identify individuals and groups at risk for diabetes that could benefit from preventive interventions. METHOD The eight FINDRISC questions were slightly modified and incorporated to Webb-QPS, an online work place survey, and distributed by e-mail to 5166 employees at Karolinska University Hospital (KUH). RESULTS The total number of responders to Webb-QPS was 3581 (69%). Of those responding 3029 (84%) replied to the FINDRISC section which comprises 59% of the original population. A group of 1082 high risk individuals could be considered for intervention whereof 298 (9.8%) are expected to develop diabetes the upcoming 10 years if left without intervention. CONCLUSION It is feasible to incorporate a diabetes risk score such as the FINDRISC in a workplace survey. A group that could be subject to preventive intervention programs was identified.

Policymakers’ perceptions of cardiovascular health in Europe

Background: Prevention of cardiovascular disease at population level has proven to be both possible and successful. The European Heart Health Charter (EHHC) outlines goals for successful cardiovascular (CV) prevention both in individuals and at a national level. The objective of this study was to explore key European health policymakers’ perceptions of their country’s proximity to the EHHC-targets and their views on obstacles to domestic CV health and on the actions needed to improve it. Design: Questionnaire, descriptive. Method: The questionnaire was distributed to health policy leaders (n = 116) within the Ministries of Health, public health institutes, cardiac societies and heart foundations in 32 European countries, assessing previous knowledge, goal fulfilment of the EHHC, perceived obstacles to CV health, actions deemed to be important to improve the CV situation, and measures to promote CV health. Results: The response rate was 68%. The general consensus was that the national CV situations were far from attaining the EHHC targets. How different health policy leaders rated the proximity to specific targets and measures did, however, not necessarily reflect the actual situation. There was a polarisation between the health policy leaders regarding obstacles to CV health and what actions are needed to improve it. There were small differences between the four professional groups and regions of the extent measures were believed to be used. Conclusion: Discrepant views on the CV situation and on the actions needed to improve it, underline the importance of information assessing the national situation and the necessity of a dialogue between organisations and policymakers responsible for CV disease throughout Europe.

Time-saving screening for diabetes in patients with coronary artery disease: a report from EUROASPIRE IV

Background WHO advocates 2-hour oral glucose tolerance test (OGTT) for detecting diabetes mellitus (DM). OGTT is the most sensitive method to detect DM in patients with coronary artery disease (CAD). Considered time consuming, the use of OGTT is unsatisfactory. A 1-hour plasma glucose (1hPG) test has not been evaluated as an alternative in patients with CAD. Objectives To create an algorithm based on glycated haemoglobin (HbA1c), fasting plasma glucose (FPG) and 1hPG limiting the need of a 2-hour plasma glucose (2hPG) in patients with CAD. Methods 951 patients with CAD without DM underwent OGTT. A 2hPG≥11.1 mmol/L was the reference for undiagnosed DM. The yield of HbA1c, FPG and 1hPG was compared with that of 2hPG. Results Mean FPG was 6.2±0.9 mmol/L, and mean HbA1c 5.8±0.4%. Based on 2hPG≥11.1 mmol/L 122 patients (13%) had DM. There was no value for the combination of HbA1c and FPG to rule out or in DM (HbA1c≥6.5%; FPG≥7.0 mmol/L). In receiver operating characteristic analysis a 1hPG≥12 mmol/L balanced sensitivity and specificity for detecting DM (both=82%; positive and negative predictive values 40% and 97%). A combination of FPG<6.5 mmol/L and 1hPG<11 mmol/L excluded 99% of DM. A combination of FPG>8.0 mmol/L and 1hPG>15 mmol/L identified 100% of patients with DM. Conclusions Based on its satisfactory accuracy to detect DM an algorithm is proposed for screening for DM in patients with CAD decreasing the need for a 2-hour OGTT by 71%.

149 Lifestyle, Blood Pressure, Lipids and Diabetes Management in Patients with Coronary Heart Disease From 24 Countries in Europe

Introduction EUROASPIRE surveys, conducted by the European Society of Cardiology in 1995-96 (9 countries), 1999-2000 (15 countries) and 2006-2007 (22 countries) showed a high prevalence of modifiable risk factors in patients with coronary heart disease (CHD) in Europe and a real potential to further reduce morbidity and mortality. The aim of the EUROASPIRE IV survey was to determine in patients with CHD whether the Joint European Societies’ guidelines on cardiovascular disease (CVD) prevention are being followed in clinical practice. Methods EUROASPIRE IV survey was undertaken in 74 centres in 24 European countries. Consecutive patients, men and women <80 years of age at the time of the index event or procedure, and with one or more of the following diagnoses: coronary artery bypass graft, percutaneous coronary intervention, acute myocardial infarction and acute myocardial ischaemia, were identified retrospectively. Data collection was based on a review of hospital medical records and a prospective interview and examination at least six months after index event or procedure. Results A total of 16,426 medical records (24.4% females) were reviewed and 7,998 patients were interviewed on average 1.4 years following their index event. At interview, 16.0% of patients smoked cigarettes, 37.6% were obese (BMI ≥ 30 kg/m2), 52.7% had central obesity (waist circumference ≥ 102 cm in men or ≥ 88 cm in women), 58.2% had raised blood pressure (BP ≥ 140/90 mmHg; ≥ 140/80 mmHg for patients with diabetes), 80.5%% had LDL cholesterol ≥ 1.8 mmol/l and 26.8% had self-reported diabetes. The use of prophylactic drug therapies was as follows: aspirin or other anti-platelets drugs 93.8%, beta-blockers 82.6%, ACE inhibitors/ARBs 75.1%, and statins 85.7%. Only 53.3% of patients using blood pressure lowering medication were controlled (BP < 140/90 mmHg; < 140/80 mmHg for patients with diabetes) and 21.1% of patients on lipid-lowering medication had achieved the LDL cholesterol goal of < 1.8 mmol/l. The therapeutic control of diabetes was unsatisfactory, with only 52.5% of patients with self-reported diabetes having HbA1c < 7.0 mmol/l. Conclusions EUROASPIRE IV shows that a large majority of coronary patients have adverse lifestyles and many do not achieve the blood pressure, lipid and diabetes targets. A wide gap continues to exist in the implementation of evidence-based medicine in cardiological practice in both hospital and primary care. There is a considerable potential to raise the standard of preventive care in Europe through preventive cardiology programmes involving multidisciplinary teams of health-care professionals helping patients to achieve the lifestyle, risk factors and therapeutic targets for CVD prevention.

Accuracy of a Simplified Glucose Measurement Device—The HemoCue Glucose 201RT

BACKGROUND Easily available, accurate glucose recordings are important when screening for and managing people with diabetes. The photometric HemoCue(®) (Ängelholm, Sweden) Glucose 201+ system, which delivers lab-comparable glucose recordings, has the drawback that its microcuvettes must be delivered and stored at 4-8°C. A newly developed system, HemoCue Glucose 201RT, has microcuvettes that can be stored at room temperature. SUBJECTS AND METHODS Participants (n=444; 18-80 years old) in the EUROASPIRE IV survey, all with coronary artery disease, some with known diabetes, were investigated. Plasma glucose recordings, fasting in all participants and postprandial in the majority, were simultaneously recorded with both pieces of equipment. Congruence was expressed as median absolute difference and median absolute relative difference between the two sets of equipment and also compared according to the International Organization for Standardization (ISO) 15197:2013 criteria. Clinical accuracy was calculated with Clarke error grid analysis and cross-tabulated while considering different glucose categories (normal, impaired glucose tolerance, and diabetes). RESULTS The median absolute difference between the two devices was +0.1 mmol/L, and the median absolute relative difference was +5.4%. This also corresponded with the ISO criteria. In the Clarke error grid, 99.8% ended up in Zones A and B, and 90% of the glucose values in the cross-table allocated the participant to the same glucose category. CONCLUSIONS The HemoCue Glucose 201RT system is accurate, with small nonsystematic deviations, when compared with the commonly used HemoCue Glucose 201+. It is predicted that the HemoCue Glucose 201RT, which is more user friendly, will be a preferred alternative to the HemoCue Glucose 201+.