Four years experience of a cardiovascular opportunistic screening and prevention programme in the primary health care in Sollentuna, Sweden. The systematic coronary risk evaluation (SCORE) for the prevention of cardiovascular diseases. Does evidence exist for its effectiveness? A systematic review Impact of socioeconomic deprivation on screening for cardiovascular disease risk in a primary prevention population: a cross-sectional study The Fremantle Primary Prevention Study: a multicentre randomised trial of absolute cardiovascular risk reduction. Does training of general practitioners for intensive treatment of people with screen-detected diabetes have a spillover effect on mortality and cardiovascular morbidity in ‘at risk’ individuals with normoglycaemia? Results from the ADDITION-Denmark cluster-randomised controlled trial Cost-effectiveness of interventions to control cardiovascular diseases and type 2 diabetes mellitus in South Asia: protocol for a systematic review Screening for diabetes using an oral glucose tolerance test within a western multi-ethnic population identifies modifiable cardiovascular risk: the ADDITION-Leicester study An integrated general practice and pharmacy-based intervention to promote the use of appropriate preventive medications among individuals at high cardiovascular disease risk: protocol for a cluster randomized controlled trial Evaluating the use of mobile phone technology to enhance cardiovascular disease screening by community health workers Acceptability, benefit and costs of early screening for hearing disability: a study of potential screening tests and models. Effect of screening for type 2 diabetes on risk of cardiovascular disease and mortality: a controlled trial among 139,075 individuals diagnosed with diabetes in Denmark between 2001 and 2009 A randomised controlled trial and cost-effectiveness study of systematic screening (targeted and total population screening) versus routine practice for the detection of atrial fibrillation in people aged 65 and over. The SAFE study. Legacy Effect of Delayed Blood Pressure-Lowering Pharmacotherapy in Middle-Aged Individuals Stratified by Absolute Cardiovascular Disease Risk: Protocol for a Systematic Review A simple risk score using routine data for predicting cardiovascular disease in primary care. The ADDITION-Cambridge trial protocol: a cluster – randomised controlled trial of screening for type 2 diabetes and intensive treatment for screen-detected patients Cardiorespiratory Fitness in Childhood and Adolescence Affects Future Cardiovascular Risk Factors: A Systematic Review of Longitudinal Studies Statins for Primary Prevention: The Debate Is Intense, but the Data Are Weak. Rationale and design of the ADDITION-Leicester study, a systematic screening programme and Randomised Controlled Trial of multi-factorial cardiovascular risk intervention in people with Type 2 Diabetes Mellitus detected by screening Is screening for AF worthwhile? Stroke risk in a screened population from the SAFE study. The Västerbotten Intervention Programme: background, design and implications National Study of Physician Awareness and Adherence to Cardiovascular Disease Prevention Guidelines Improving diabetes care: multi-component cardiovascular disease risk reduction strategies for people with diabetes in South Asia--the CARRS multi-center translation trial. The impact of a point-of-care testing device on CVD risk assessment completion in New Zealand primary-care practice: A cluster randomised controlled trial and qualitative investigation Motivational interviewing and problem solving treatment to reduce type 2 diabetes and cardiovascular disease risk in real life: a randomized controlled trial Evaluation of a toolkit to improve cardiovascular disease screening and treatment for people with type 2 diabetes: protocol for a cluster-randomized pragmatic trial Evaluating the impact of population and high-risk strategies for the primary prevention of cardiovascular disease. Cardiovascular disease risk reduction in rural China: a clustered randomized controlled trial in Zhejiang Screening for Type 2 Diabetes Mellitus: A Cost-Effectiveness Analysis Randomised controlled trial comparing uptake of NHS Health Check in response to standard letters, risk-personalised letters and telephone invitations Rationale and design of the Rural Andhra Pradesh Cardiovascular Prevention Study (RAPCAPS): a factorial, cluster-randomized trial of 2 practical cardiovascular disease prevention strategies developed for rural Andhra Pradesh, India. Reducing salt intake for prevention of cardiovascular diseases in high-risk patients by advanced health education intervention (RESIP-CVD study), Northern Thailand: study protocol for a cluster randomized trial Global Risk Assessment to Guide Blood Pressure Management in Cardiovascular Disease Prevention Economic evaluation of a lifestyle intervention in primary care to prevent type 2 diabetes mellitus and cardiovascular diseases: a randomized controlled trial Aspirin for primary prevention: yes or no? Lifestyle‐Based Prediction Model for the Prevention of CVD: The Healthy Heart Score The South Asian Heart Lifestyle Intervention (SAHELI) study to improve cardiovascular risk factors in a community setting: design and methods.
OBJECTIVE To study the feasibility of a cardiovascular prevention programme . DESIGN Opportunistic screening for cardiovascular risk factors . Advice and treatment to reduce identified cardiovascular risk factors . Individually design ed follow-up . SETTING Primary health care in Sollentuna ( 51,000 inhabitants ) , Sweden . SUBJECTS Visitors to health care centres . MAIN OUTCOME MEASURES Feasibility and effectiveness to reduce identified cardiovascular risk factors . RESULTS During 4 years 5622 persons , of whom 4655 ( 83 % ) were in the age group 20 - 60 years , participated in the programme . The prevalences of risk factors as smoking , overweight , hypertension , hypercholesterolaemia and hypertriglyceridaemia were high . At follow-up investigations , mean S-cholesterol levels were reduced by 7 % among men and 10 % among women . S-triglycerides were reduced by 24 % and 42 % , respectively . Diastolic blood pressures were reduced in men from 95 to 90 mmHg and in women from 94 to 88 mmHg . However , no effects on weight were noted and due to a low follow-up rate meaningful analysis of smoking habits was not possible . CONCLUSION A programme for cardiovascular screening and prevention can be integrated in the primary health care system . Prevalent cardiovascular risk factors like hypercholesterolaemia , hypertriglyceridaemia and high blood pressure were significantly reduced after intervention Objectives : The SCORE model predicts the ten-year risk of cardiovascular mortality but it is still unknown whether applying the SCORE in clinical practice subsequently improves cardiovascular disease ( CVD ) outcomes . The objective of this study is to assess the effect of total cardiovascular risk estimation using the SCORE in preventing serious cardiovascular events in European adults without prior CVD . Methods and results : Data sources : eight bibliographical data bases ( 2003 – August 2015 ) , other internet sources and reference lists of articles were checked . This was supplemented by contact with the board members of the European Society of Cardiology ( ESC ) and the authors of the SCORE model . Study eligibility criteria : all prospect i ve studies in any language investigating the effect of using the SCORE on the clinical outcome ( CVD death , major events and adverse outcomes ) in an adult population were examined . Two review ers assessed the studies independently ( titles , abstract s , full texts ) . After removal of duplicates , 5,256 records were screened and 14 full text papers considered . No eligible studies were identified . An extensive literature search revealed no r and omized control trial or other prospect i ve study comparing significant clinical outcomes between groups that used the SCORE and those who did not . Conclusions : The effect of using the SCORE ( with or without subsequent intervention ) on CVD death , all-cause mortality , major CVD events like myocardial infa rct ion and stroke , as well as adverse outcomes , is still unknown . A cluster r and omised controlled trial is warranted to evaluate the use of the SCORE on important outcomes Objectives Investigate the association between socioeconomic deprivation and completeness of cardiovascular disease ( CVD ) risk factor recording in primary care , uptake of screening in people with incomplete risk factor recording and with actual CVD risk within the screened subgroup . Design Cross-sectional study . Setting Nine UK general practice s. Participants 7987 people aged 50–74 years with no CVD diagnosis . Methods CVD risk was estimated using the Framingham equation from data extracted from primary care electronic health records . Where there was insufficient information to calculate risk , patients were invited to attend a screening assessment . Analysis Proportion of patients for whom clinical data were sufficiently complete to enable CVD risk to be calculated ; proportion of patients invited to screening who attended ; proportion of patients who attended screening whose 10-year risk of a cardiovascular event was high ( > 20 % ) . For each outcome , a set of logistic regression models were run . Crude and adjusted ORs were estimated for person-level deprivation , age , gender and smoking status . We included practice -level deprivation as a continuous variable and practice as a r and om effect to account for clustering . Results People who had lower  Indices of Multiple Deprivation ( IMD ) scores ( less deprived ) had significantly worse routine CVD risk factor recording ( adjusted OR 0.97 ( 0.95 to 1.00 ) per IMD decile ; p=0.042 ) . Screening attendance was poorer in those with more deprivation ( adjusted OR 0.89 ( 0.86 to 0.91 ) per IMD decile ; p<0.001 ) . Among those who attended screening , the most deprived were more likely to have CVD risk > 20 % ( OR 1.09 ( 1.03 to 1.15 ) per IMD decile ; p=0.004 ) . Conclusions Our data suggest that those who had the most to gain from screening were least likely to attend , potentially exacerbating existing health inequalities . Future research should focus on tailoring the delivery of CVD screening to ensure engagement of socioeconomically deprived groups BACKGROUND Cardiovascular disease ( CVD ) is the leading cause of global mortality . Risk factor management in clinical practice often relies on relative risk modification rather than the more appropriate absolute risk assessment . AIM To determine whether patients receiving more-frequently design ated GP visits had increased benefit in terms of their absolute CVD risk assessment , as compared with patients in receipt of their usual GP care . DESIGN AND SETTING Prospect i ve , open , pragmatic block r and omised study in a 1:1 group allocation ratio in three Western Australian general practice s. METHOD A convenience sample ( n = 1200 ) of patients aged 40 - 80 years were r and omised to 3-monthly GP visits ( five in total for the intensive ) or usual GP care ( two in total for the opportunistic ) , with 12 months ' follow-up . The main outcome was absolute CVD risk scores based on the New Zeal and Cardiovascular Risk Calculator . Others outcome measures were weight , height , waist circumference , blood pressure , and fasting blood lipids and glucose . RESULTS There were 600 patients per group at baseline . At 12 months ' analysis there were 543 in the intensive group and 569 in the opportunistic group . Mean ( st and ard deviation [ SD ] ) absolute CVD risk reduced significantly between baseline and 12 months in the intensive group ( 6.28 % [ 5.11 ] to 6.10 % [ 4.94 ] ) but not in the opportunistic group ( 6.27 % [ 5.10 ] to 6.24 % [ 5.38 ] ) . There was a significant reduction between baseline and 12 months in mean ( SD ) total cholesterol ( 5.28 mmol/l [ 0.94 ] to 5.08 mmol/l [ 0.96 ] ) ; low-density lipoprotein cholesterol ( 3.08 mmol/l [ 0.87 ] to 2.95 mmol/l [ 0.89 ] ) ; triglyceride ( 1.45 mmol/l [ 0.86 ] to 1.36 mmol/l [ 0.84 ] ) ; and in mean ( SD ) waist circumference in men ( 98.74 cm [ 10.70 ] to 97.13 cm [ 10.20 ] ) and females ( 90.64 cm [ 14.62 ] to 88.96 cm [ 14.00 ] ) in the intensive group . CONCLUSION A targeted approach using absolute risk calculators can be used in primary care to modify global CVD risk assessment Aims /hypothesisWithin a trial of intensive treatment of people with screen-detected diabetes , we aim ed to assess a potential spillover effect of the trial intervention on incident cardiovascular disease ( CVD ) and all-cause mortality among people who screened positive on a diabetes risk question naire but who were normoglycaemic . Methods In the Anglo – Danish – Dutch Study of Intensive Treatment In People with Screen-Detected Diabetes in Primary Care (ADDITION)-Denmark trial , 175 general practice s were cluster-r and omised into : ( 1 ) screening plus routine care of individuals with screen-detected diabetes ( control group ) ;  or (  2 ) screening plus training and support in intensive multifactorial treatment of individuals with screen-detected diabetes ( intervention  group  ) . We identified all individuals who screened positive on a diabetes risk question naire in ADDITION-Denmark but were normoglycaemic following biochemical testing for use in this secondary analysis . After a median 8.9 years follow-up , we used data from national registers to compare rates of first CVD events and all-cause mortality in individuals in the routine care group with those in the intensive treatment group . Results In total , 21,513 individuals screened positive for high risk of diabetes but were normoglycaemic on biochemical testing in ADDITION-Denmark practice s between 2001 and 2006 ( 10,289 in the routine care group and 11,224 in the intensive treatment group ) . During 9 years of follow-up , there were 3784 first CVD events and 1748 deaths . The incidence of CVD was lower among the intensive treatment group compared with the routine care group ( HR 0.92 [ 95 % CI 0.85 , 0.99 ] ) . This association was stronger among individuals at highest CVD risk ( heart SCORE ≥ 10 ; HR 0.85 [ 95 % CI 0.75 , 0.96 ] ) . There was no difference in mortality between the two treatment groups ( HR 1.02 [ 95 % CI 0.92 , 1.14 ] ) . Conclusions /interpretationTraining of general practitioners to provide target-driven intensive management of blood glucose levels and other cardiovascular risk factors showed some evidence of a spillover effect on the risk of CVD over a 9 year period among individuals at high risk of diabetes . The effect was particularly pronounced among those at highest risk of CVD . There was no effect on mortality . Trial registration : Clinical Trials.gov Introduction While a number of strategies are being implemented to control cardiovascular diseases ( CVDs ) and type 2 diabetes mellitus ( T2DM ) , the cost-effectiveness of these in the South Asian context has not been systematic ally evaluated . We aim to systematic ally review the economic ( cost-effectiveness ) evidence available on the individual- , group- and population -level interventions for control of CVD and T2DM in South Asia . Methods and analysis This review will consider all relevant economic evaluations , either conducted alongside r and omised controlled trials or based on decision modelling estimates . These studies must include participants at risk of developing CVD/T2DM or with established disease in one or more of the South Asian countries ( India , Bangladesh , Pakistan , Sri Lanka , Nepal , Maldives , Bhutan and Afghanistan ) . We will identify relevant papers by systematic ally search ing all major data bases and registries . Selected articles will be screened by two independent research ers . Method ological quality of the studies will be assessed using a modified Drummond and a Phillips checklist . Cochrane guidelines will be followed for bias assessment in the effectiveness studies . Results Results will be presented in line with the PRISMA ( Preferred Reporting Items for Systematic review and Meta- analysis ) checklist , and overall quality of evidence will be presented as per the GRADE ( Grade s of Recommendation , Assessment , Development and Evaluation ) approach . Ethics and dissemination The study has received ethics approval from the All India Institute of Medical Sciences , New Delhi , India . The results of this review will provide policy-relevant recommendations for the uptake of cost-effectiveness evidence in prioritising decisions on essential chronic disease care packages for South Asia . Study registration number PROSPERO CRD42013006479 Aims /hypothesisThe aim of this study was to determine the frequency of undiagnosed glucose abnormalities and the burden of cardiovascular disease ( CVD ) risk among south Asians and white Europeans attending a systematic screening programme for type 2 diabetes ( ADDITION-Leicester ) and to estimate the achievable risk reduction in individuals identified with glucose disorders . Methods R and om sample s of individuals ( n = 66,320 ) from 20 general practice s were invited for a 75 g OGTT and CVD risk assessment .  Ten-year CVD risk among screen-detected people with diabetes or impaired glucose regulation ( IGR )  ( impaired fasting glycaemia and /or impaired glucose tolerance [ IGT ] ) was computed using the Framingham-based ETHRISK engine and achievable risk reduction was predicted using relative reductions for treatments extracted from published trials . Results A total of 6,041 participants ( 48 % male , 22 % south Asian ) aged 40–75 years inclusive were included .  Undiagnosed glucose disorders occurred more frequently in south Asians than white Europeans ; age and sex adjusted odds ratios were 1.74 ( 95 % CI 1.42–2.13 ) and 2.30 ( 95 % CI 1.68–3.16 ) for IGT and diabetes respectively . Prevalence of any undetected glucose disorder was 17.5 % in the whole cohort . Adjusted 10-year risk was similar in screen-detected people with IGR and diabetes ( 18.3 % vs 21.6 % ) , and was higher in south Asians across the glucose spectrum . Absolute CVD risk reductions of up to 13 % in those with screen-detected type 2 diabetes and 6 % in IGR are achievable using existing cardioprotective therapies . Conclusions /interpretation Population screening with an OGTT identifies a significant burden of modifiable CVD risk , especially within south Asian groups . Strategies enticing this population to consider screening programmes are urgently needed as significant risk reduction is possible once a glucose abnormality is identified . Trial registration : Clinical Trials.gov NCT00318032 Funding : The project is funded for support and treatment costs by NHS Department of Health Support for Science and project grants Background Cardiovascular diseases ( CVD ) are responsible for significant morbidity , premature mortality , and economic burden . Despite established evidence that supports the use of preventive medications among patients at high CVD risk , treatment gaps remain . Building on prior evidence and a theoretical framework , a complex intervention has been design ed to address these gaps among high-risk , under-treated patients in the Australian primary care setting . This intervention comprises a general practice quality improvement tool incorporating clinical decision support and audit/feedback capabilities ; availability of a range of CVD polypills ( fixed-dose combinations of two blood pressure lowering agents , a statin ± aspirin ) for prescription when appropriate ; and access to a pharmacy-based program to support long-term medication adherence and lifestyle modification . Methods Following a systematic development process , the intervention will be evaluated in a pragmatic cluster r and omized controlled trial including 70 general practice s for a median period of 18 months . The 35 general practice s in the intervention group  will work with a nominated partner pharmacy , whereas those in the control group will provide usual care without access to the intervention tools . The primary outcome is the proportion of patients at high CVD risk who were inadequately treated at baseline who achieve target blood pressure ( BP ) and low-density lipoprotein cholesterol ( LDL-C ) levels at the study end . The outcomes will be analyzed using data from electronic medical records , utilizing a vali date d extraction tool . Detailed process and economic evaluations will also be performed . Discussion The study intends to establish evidence about an intervention that combines technological innovation with team collaboration between patients , pharmacists , and general practitioners ( GPs ) for CVD prevention . Trial registration Australian New Zeal and Clinical Trials Registry BACKGROUND Primary prevention of cardiovascular disease (CVD),by identifying individuals at risk is a well-established , but costly strategy when based on measurements that depend on laboratory analyses . A non-laboratory , paper-based CVD risk assessment chart tool has previously been developed to make screening more affordable in developing countries . Task shifting to community health workers ( CHWs ) is being investigated to further scale CVD risk screening . This study aim ed to develop a mobile phone CVD risk assessment application and to evaluate its impact on CHW training and the duration of screening for CVD in the community by CHWs . METHODS A feature phone application was developed using the open source online platform , CommCare ( © ) . CHWs ( n=24 ) were trained to use both paper-based and mobile phone CVD risk assessment tools . They were r and omly allocated to using one of the risk tools to screen 10 - 20 community members and then crossed over to screen the same number , using the alternate risk tool . The impact on CHW training time , screening time and margin of error in calculating risk scores was recorded . A focus group discussion evaluated experiences of CHWs using the two tools . RESULTS The training time was 12.3h for the paper-based chart tool and 3h for the mobile phone application . 537 people were screened . The mean screening time was 36 min ( SD=12.6 ) using the paper-base chart tool and 21 min ( SD=8.71 ) using the mobile phone application , p=<0.0001 . Incorrect calculations ( 4.3 % of average systolic BP measurements , 10.4 % of BMI and 3.8 % of CVD risk score ) were found when using the paper-based chart tool while all the mobile phone calculations were correct . Qualitative findings from the focus group discussion corresponded with the findings of the pilot study . CONCLUSION The reduction in CHW training time , CVD risk screening time , lack of errors in calculation of a CVD risk score and end user satisfaction when using a mobile phone application , has implication s in terms of adoption and sustainability of this primary prevention strategy to identify people with high CVD risk who can be referred for appropriate diagnoses and treatment OBJECTIVES To show that hearing loss has such a high prevalence in the older population to justify screening , if effective and acceptable methods are available ; and that population take-up and benefit can make a measurable outcome difference in quality of life . DESIGN A population study of people aged 55 - 74 years was undertaken . A clinical effectiveness study of differently organised screening programmes was carried out using a controlled trial to identify those who might benefit from intervention ( and the extent of the benefit ) . A retrospective case-control study examined the very long-term ( more than 10 years ) compliance of patients in using their hearing aids after early identification and determined the extent to which early-identified hearing-impaired people have better outcomes than equivalent people identified later . An examination of the costs and cost-effectiveness of different potential screening programmes was also undertaken . SETTING A population study was design ed in the UK , with specific stages being conducted in more depth on a sample of people from Nottingham and Southampton . The clinical effectiveness study was conducted in general practice s in Nottingham and Bath using a systematic or opportunistic screen . The retrospective case-control study compared a group of early-identified hearing aid users , with control matched for age , gender and occupation , in Cardiff , Glasgow and Manchester . PARTICIPANTS In Great Britain responses were obtained for 34,362 individuals from the postal question naire as part of a population study , 506 were interviewed , 351 were assessed for benefit from amplification and 87 were fitted with a hearing aid . The clinical effectiveness study received 1461 replies from the first-stage question naire screen , with 306 people assessed in the clinic , of whom 156 were fitted with hearing aids . The retrospective case-control study traced 116 previously fitted hearing aid users , who had been identified by a screen , and then conducted a case-control using 50 of these for whom complete data were available , matching with two control groups of 50 people . INTERVENTIONS The major prospect i ve interventions were to introduce amplification through offering people , with minimal hearing impairment , hearing aid(s ) in a rehabilitative setting . In the population study , aids were offered as a monaural in-the-ear ( ITE ) hearing aid and in the clinical effectiveness study people who met the criteria were r and omised to be offered two different ITE hearing aids to be fitted bilaterally . The retrospective case-control study used unilateral and bilateral hearing aids . MAIN OUTCOME MEASURES Prevalence of hearing problems and degree to which services meet need in 55 - 74-year age group .  Public acceptability and individual benefits of hearing screening and intervention as a function of demographic and hearing domain-specific characteristics . Improvement in quality of life . Screening costs and cost-effectiveness as a function of proposed programmes . RESULTS It was found that 12 % of people aged 55 - 74 years have a hearing problem that causes moderate or severe worry , annoyance or upset , 14 % have a bilateral hearing impairment of at least 35 dB hearing level ( HL ) and only 3 % currently receive intervention , through the use of hearing aids .  Good amplification was shown to benefit about one in four of this 55 - 74-year-old population and the degree of hearing loss predicted benefit well . Overall , there was a strong correlation between benefit from amplification and from using hearing aids . Question naires and audiometric screens gave good screening operating characteristics . The systematic screening programme was more acceptable and gave a better response than the opportunistic . About 70 % of those who were offered an aid accepted a bilateral fitting . This increased to 95 % for those with > or = 35 dB HL ( averaged over 0.5 , 1 , 2 and 4 kHz in the better ear ) . The retrospective case-control study showed that long-term hearing aid use was low , unless hearing impairment was quite high ( e.g. > 35 dB HL ) . Those identified early had greater benefit through additional years of use/better adaptation to use than those of the same age and hearing impairment who were fitted with hearing aids later . Different screening programmes were modelled . The 35 dB HL better ear average hearing impairment level was found to be a good , robust and justifiable target group for screening and here the most efficient and practicable method was to use two questions in primary care concerning hearing problems and a hearing screen using a pure tone at 3 kHz 35 dB HL . The average cost of the screening programme was 13 pounds per person screened or about 100 pounds if treatment costs were included . Making the conservative assumption that identification gives an extra 9 years using hearing aids , the costs of screening and intervention were in the range of 800 - 1000 pounds per quality -adjusted life-year when using the Health Utilities Index and about 2500 pounds using the Short Form 6 Dimensions metric . CONCLUSIONS A simple systematic screen , using an audiometric screening instrument , has been shown to be acceptable to people in the age range 55 - 74 years , is likely to provide substantial benefit and may be cost-effective to those in that target group . Hearing screening appears to meet the National Screening Committee 's criteria in most respects , provided screening is targeted at those with at least 35 dB HL better ear average . Based on the research carried out here there is sufficient evidence to support a larger and more definitive study of hearing screening . Further research into who should be referred for and benefit from audiological assessment and provision of hearing aid in a primary care trust setting is needed as is investigation into screening devices and the various aspects of introducing such a programme Aims /hypothesisThere is continuing debate about the net benefits of population screening for type 2 diabetes . We compared the risk of cardiovascular disease ( CVD ) and mortality among incident cases of type 2 diabetes in a  screened group with those in an unscreened group . Methods In this register-based non-r and omised controlled trial , eligible individuals were all men and women aged 40–69 years without known diabetes , registered with a general practice in Denmark ( n = 1,912,392 ) . Between 2001 and 2006 , 153,107 individuals registered with 181 practice s participating in the Anglo – Danish – Dutch Study of Intensive Treatment in People with Screen-Detected Diabetes in Primary Care (ADDITION)-Denmark study were sent a diabetes-risk-score question naire . Individuals at moderate-to-high risk were invited to visit their family doctor for assessment of diabetes status and cardiovascular risk ( screening group ) . The 1,759,285 individuals registered with all other practice s in Denmark constituted the retrospectively constructed no-screening ( control ) group . In this post hoc analysis , we identified individuals from the  screening and no-screening groups who were diagnosed with diabetes between 2001 and 2009 ( n = 139,075 ) , and compared risk of CVD and mortality in these groups between 2001 and 2012 . Results In the screening group , 27,177/153,107 ( 18 % ) individuals attended for screening , of whom 1533 were diagnosed with diabetes . Between 2001 and 2009 , 13,992 people were newly diagnosed with diabetes in the screening group ( including those diagnosed by screening ) and 125,083 in the no-screening group . Between 2001 and 2012 , the risks of CVD and mortality were lower among individuals with diabetes in the screening group compared with individuals with diabetes in the no-screening ( control ) group ( CVD HR 0.84 , 95 % CI 0.80 , 0.89 ; mortality HR 0.79 , 95 % CI 0.74 , 0.84 ) . Conclusions /interpretationA single round of diabetes screening and cardiovascular risk assessment in middle-aged Danish adults in general practice was associated with a significant reduction in risk of all-cause mortality and CVD events in those diagnosed with diabetes OBJECTIVES To determine the most cost-effective method of screening for  atrial fibrillation ( AF ) in the population aged 65 years and over , as well as its prevalence and incidence in this age group . Also to evaluate the relative cost-effectiveness of different methods of recording and interpreting the electrocardiogram ( ECG ) within a screening programme . DESIGN Multicentred r and omised controlled trial . Purpose fully selected general practice s were r and omly allocated to 25 intervention practice s and 25 control practice s. SETTING Fifty primary care centres across the West Midl and s , UK . PARTICIPANTS Patients aged 65 years and over . INTERVENTIONS GPs and practice nurses in the intervention practice s received education on the importance of AF detection and ECG interpretation . Patients in the intervention practice s were r and omly allocated to systematic ( n = 5000 ) or opportunistic screening ( n = 5000 ) . Prospect i ve identification of pre-existing risk factors for AF within the screened population enabled comparison between targeted screening of people at higher risk of AF and total population screening . MAIN OUTCOME MEASURES AF detection rates in systematic ally screened and opportunistically screened population s in the intervention practice s were compared with AF detection rate in 5000 patients in the control practice s. The screening period was 12 months . RESULTS Baseline prevalence of AF was 7.2 % , with a higher prevalence in males ( 7.8 % ) and patients aged 75 years and over ( 10.3 % ) . The control population demonstrated higher baseline prevalence ( 7.9 % ) than either the systematic ( 6.9 % ) or opportunistic ( 6.9 % ) intervention population . In the control population 47 new cases were detected ( incidence 1.04 % per year ) . In the opportunistic arm 243 patients without a baseline diagnosis of AF were found to have an irregular pulse , with 177 having an ECG , yielding 31 new cases ( incidence 0.69 % per year ) . A further 44 cases were detected outside the screening programme ( overall incidence 1.64 % per year ) . In the systematic arm 2357 patients had an ECG yielding 52 new cases ( incidence 1.1 % per year ) . Of these , 31 were detected by targeted screening and a further 21 by total population screening . A further 22 cases were detected outside the screening programme ( overall incidence 1.62 % per year ) . In terms of ECG interpretation , computerised decision support software ( CDSS ) gave a sensitivity of 87.3 % , a specificity of 99.1 % and a positive predictive value ( PPV ) of 89.5 % compared with the gold st and ard ( cardiologist reporting ) . GPs and practice nurses performed less well . The only difference in performance between intervention population s and controls was that practice nurses from the control arm performed less well than with intervention practice nurses on interpretation of limb-lead ( PPV 38.8 % versus 20.8 % ) and single-lead ( PPV 37.7 % versus 24.0 % ) ECGs . The within-trial economic evaluation results showed the lowest incremental cost to be for the opportunistic arm , with an incremental cost-effectiveness ratio of 337 pounds Sterling for each additional case detected compared to the control arm . Opportunistic screening dominated both more intensive screening strategies . Model-based analyses showed small differences in cost and quality -adjusted life-years for different methods and intensities of screening , but annual opportunistic screening result ed in the lowest number of ischaemic strokes and greatest proportion of cases of AF diagnosed . Probabilistic sensitivity results indicated that there was a probability of approximately 60 % that screening from the age of 65 years was cost-effective in both men and women . CONCLUSIONS The results of the study indicated that in terms of a screening programme for atrial fibrillation in patients 65 and over , the only strategy that improved on routine practice was opportunistic screening , model-based analyses indicated that there was a probability of approximately 60 % of annual opportunistic screening being cost effective . It is suggested that the following topics are worthy of further investigation : the effect of the implementation of a screening programme for AF on the uptake and maintenance of anticoagulation in patients aged 65 years and over ; an evaluation of the role of CDSS in the diagnosis of cardiac arrythmias ; the best method for routinely detecting paroxysmal AF ; ways of improving healthcare professionals ' performance in ECG interpretation ; development of a robust economic model to incorporate data on new therapeutic agents for use as thromboprophylactic agents for patients with AF , and an evaluation of the relative risk of stroke for patients with incident as opposed to prevalent AF Background Many national and international guidelines recommend that the initiation of blood pressure (BP)-lowering drug treatment for the primary prevention of cardiovascular disease ( CVD ) should no longer be based on BP level alone , but on absolute cardiovascular risk . While BP-lowering drug treatment is beneficial in high-risk individuals at any level of elevated BP , clinicians are concerned about legacy effects on patients with low-to-moderate risk and mildly elevated BP who remain “ untreated ” . Objective We aim to investigate the legacy effect of delayed BP-lowering pharmacotherapy in middle-aged individuals ( 45 - 65 years ) with mildly elevated BP ( systolic BP 140 - 159 mmHg and /or diastolic BP 90 - 99 mmHg ) stratified by absolute risk for primary prevention of CVD , but particularly in the low-risk ( < 10 % five-year absolute risk ) group . Methods R and omized trials of BP-lowering therapy versus placebo or pretreated subjects in active comparator studies with posttrial follow-up will be identified using a 2-step process . First , r and omized trials of BP-lowering therapy will be identified by ( 1 ) retrieving the references of trials included in published systematic review s of BP-lowering therapy , ( 2 ) retrieving studies published by the Blood Pressure Lowering Treatment Trialists ’ Collaboration ( BPLTTC ) , and ( 3 ) checking studies referenced in the 1993 World Health Organization/International Society of Hypertension meeting memor and um on BP management . Posttrial follow-up studies will then be identified by forward citation search ing the r and omized trials identified in step 1 through Web of Science . The search will include r and omized controlled trials with at least 1-year in-trial period and a posttrial follow-up phase . Age is the major determinant of absolute cardiovascular risk , so the participants in our review will be restricted to middle-aged adults who are more likely to have a lower cardiovascular risk profile . The primary outcome will be all-cause mortality . Secondary outcomes will include cardiovascular mortality , fatal stroke , fatal myocardial infa rct ion , and death due to heart failure . Results The search es for existing systematic review s and BPLTTC studies were piloted and modified . The study is expected to be completed before June 2018 . Conclusions The findings of this study will contribute to the body of knowledge concerning the beneficial , neutral , or harmful effects of delayed BP-lowering drug treatment on the primary prevention of CVD in patients with mildly elevated BP and low-to-moderate CVD risk . Trial Registration PROSPERO International Prospect i ve Register of Systematic Review s : CRD42017058414 ; https://www.crd.york.ac.uk/ PROSPERO /display_record.asp?ID = CRD42017058414 ( Archived by WebCite ® at http://www.webcitation.org/6t6sa8O2Q BACKGROUND Population -based screening for cardiovascular disease ( CVD ) risk , incorporating blood tests , is proposed in several countries . AIM The aim of this study was to evaluate whether a simple approach to identifying individuals at high risk of CVD using routine data might be effective . DESIGN OF STUDY Prospect i ve cohort study ( EPIC-Norfolk ) . SETTING Norfolk area , UK . METHOD A total of 21 867 men and women aged 40 - 74 years , who were free from CVD and diabetes at baseline , participated in the study . The discrimination ( the area under the receiver operating characteristic curve [ aROC ] ) , calibration , sensitivity/specificity , and positive/negative predictive value were evaluated for different risk thresholds of the Framingham risk equations and the Cambridge diabetes risk score ( as an example of a simple risk score using routine data from electronic general practice records ) . RESULTS During 203 664 person-years of follow-up , 2213 participants developed a first CVD event ( 10.9 per 1000 person-years ) . The Cambridge diabetes risk score predicted CVD events reasonably well ( aROC 0.72 ; 95 % confidence interval [ CI ] = 0.71 to 0.73 ) , while the Framingham risk score had the best predictive ability ( aROC 0.77 ; 95 % CI = 0.76 to 0.78 ) . The Framingham risk score overestimated risk of developing CVD in this representative British population by 60 % . CONCLUSION A risk score incorporating routinely available data from GP records performed reasonably well at predicting CVD events . This suggests that it might be more efficient to use routine data as the first stage in a stepwise population screening programme to identify people at high risk of developing CVD before more time- and re source -consuming tests are used Background The increasing prevalence of type 2 diabetes poses a major public health challenge . Population -based screening and early treatment for type 2 diabetes could reduce this growing burden . However , the benefits of such a strategy remain uncertain . Methods and design The ADDITION-Cambridge study aims to evaluate the effectiveness and cost-effectiveness of ( i ) a stepwise screening strategy for type 2 diabetes ; and ( ii ) intensive multifactorial treatment for people with screen-detected diabetes in primary care . 63 practice s in the East Anglia region participated . Three undertook the pilot study , 33 were allocated to three groups : no screening ( control ) , screening followed by intensive treatment ( IT ) and screening plus routine care ( RC ) in an unbalanced ( 1:3:3 ) r and omisation . The remaining 27 practice s were r and omly allocated to IT and RC . A risk score incorporating routine practice data was used to identify people aged 40–69 years at high-risk of undiagnosed diabetes . In the screening practice s , high-risk individuals were invited to take part in a stepwise screening programme . In the IT group , diabetes treatment is optimised through guidelines , target-led multifactorial treatment , audit , feedback , and academic detailing for practice teams , alongside provision of educational material s for newly diagnosed participants . Primary endpoints are modelled cardiovascular risk at one year , and cardiovascular mortality and morbidity at five years after diagnosis of diabetes . Secondary endpoints include all-cause mortality , development of renal and visual impairment , peripheral neuropathy , health service costs , self-reported quality of life , functional status and health utility . Impact of the screening programme at the population level is also assessed through measures of mortality , cardiovascular morbidity , health status and health service use among high-risk individuals . Discussion ADDITION-Cambridge is conducted in a defined high-risk group accessible through primary care . It addresses the feasibility of population -based screening for diabetes , as well as the benefits and costs of screening and intensive multifactorial treatment early in the disease trajectory . The intensive treatment algorithm is based on evidence from studies including individuals with clinical ly diagnosed diabetes and the education material s are informed by psychological theory . ADDITION-Cambridge will provide timely evidence concerning the benefits of early intensive treatment and will inform policy decisions concerning screening for type 2 diabetes . Trial registration Current Controlled trials IS RCT Background Although cardiorespiratory fitness ( CRF ) in childhood and adolescence may be linked to future cardiovascular health , there is currently limited evidence for a longitudinal association . Objectives To provide a systematic review on the prospect i ve association between CRF in childhood and adolescence and cardiovascular disease ( CVD ) risk factors at least 2 years later . Methods Using a systematic search of Medline , Embase , and SPORTD iscus , relevant articles were identified by the following criteria : generally healthy children and adolescents between 3 and 18 years of age with CRF assessed at baseline , and a follow-up period of ≥ 2 years . The outcome measures were CVD risk factors . We appraised quality of the included articles with STROBE and QUIPS checklists . Results After screening 7524 titles and abstract s , we included 38 articles , assessing 44,169 children and adolescents followed up for a median of 6 years . Eleven articles were of high quality . There was considerable heterogeneity in methodology , measurement of CRF , and outcomes , which hampered meta- analysis . In approximately half of the included articles higher CRF in childhood and adolescence was associated with lower body mass index ( BMI ) , waist circumference , body fatness and lower prevalence of metabolic syndrome in later life . No associations between CRF in childhood and adolescence and future waist-to-hip ratio , blood pressure , lipid profile , and glucose homeostasis were observed . Conclusion Although about half of the included articles reported inverse associations between CRF in childhood and adolescence and future BMI , body fatness , and metabolic syndrome , evidence for other CVD risk factors was unconvincing . Many articles did not account for important confounding factors such as adiposity . Recommendations for future research include st and ardizing the measurement of CRF , i.e. by reporting VO2max , using st and ardized outcome assessment s , and performing individual patient data meta-analyses This issue of JAMA contains the latest US Preventive Services Task Force ( USPSTF ) recommendation statement on statins for prevention of cardiovascular disease in adults,1 along with the accompanying evidence report and systematic review 2 on which the recommendations are based . The evidence report summarized data from 19 trials including a total of 71 344 patients and concluded that statin therapy was associated with reduced risk of all-cause and cardiovascular mortality and cardiovascular disease ( CVD ) events . Thus , the task force recommended “ initiating use of lowto moderate-dose statins in adults aged 40 to 75 years without a history of CVD who have 1 or more CVD risk factors and a calculated 10-year CVD event risk of 10 % or greater ( B recommendation ) ” or “ 7.5 % to 10 % ( C recommendation ) .”1 Although the task force did their usual careful job of review ing the evidence , the evidence for treating asymptomatic persons with statins does not appear to merit a grade B or even a grade C recommendation . The task force evidence report estimated an absolute benefit for use of statins of 0.40 % for all-cause mortality and 0.43 % for cardiovascular mortality and indicated that the absolute benefit was greater for patients at greater baseline risk.2 Notably , the evidence report did not exclude studies that included patients taking statins for secondary prevention , who have a higher baseline risk of cardiac events and death and thus are more likely to benefit from therapy that inflates the benefit attributed to a primary prevention population . The task force did perform a sensitivity analysis that excluded 3 trials with persons for whom there were prior “ hard ” cardiovascular events and obtained similar results of benefits ( eTable 5 in the article by Chou et al2 ) . This sensitivity analysis did not exclude WOSCOPS , which included patients receiving statins for secondary prevention—5 % had angina and 3 % had intermittent claudication,3 accounting for 15 % of the total weight in the meta- analysis . In contrast , a meta- analysis of 11 studies and 65 229 patients receiving statins for primary prevention , in which patients receiving statins for secondary prevention were excluded , found no benefit of statins for reducing all-cause mortality.4 The confidence intervals of these 2 analyses overlap , and the difference between these findings likely reflects differences in studies included . The USPSTF and authors of the evidence report did not have access to the primary data ( clinical study reports and anonymized patient-level data ) from the statin clinical trials . Rather , they had to rely on peer- review ed published reports as the basis for these recommendations . Exacerbating the potential bias , all of the trials included in the task force evidence report2 were industry-sponsored except 1 trial,5 and that trial contributed 0.2 % of the weight to the mortality calculation . Industry-sponsored studies have been shown to report greater benefit and lesser adverse effects than noncommercially sponsored trials of the same drugs.6 Whether this is true for statins and primary prevention of CVD is unknown . Among the 19 r and omized clinical trials of statins vs placebo or no statin included in the evidence report for the task force recommendations , only 15 reported all-cause mortality , 10 reported cardiovascular mortality , 12 reported fatal and nonfatal myocardial infa rct ion  , and 13 reported fatal and nonfatal stroke.2,7  Reliance on selective reporting of the most important outcomes , which are likely included in the clinical trial data , makes reporting bias possible . Furthermore , after allcause mortality , the comparative incidence of serious adverse events between treatment and control groups is arguably the second most important measure of the effect of active therapy in r and omized clinical trials . Underst and ing the evidence base in evaluating harms of statin therapy is also critically important . Although the benefits of any preventive therapy accrue according to risk of disease ( greater benefit in higher-risk patients ) , the harms of therapy usually distribute equally over all risk levels . Thus , persons at low risk have little chance of benefit but equal chance of harms and thus are more likely to have a net harm . The evidence base for harms of statins , despite the introduction of these drugs more than 20 years ago , is incomplete . Many of the trials did not ask about commonly reported statin effects , such as muscle pains and weakness , and only recorded myopathy , for which an increase in creatine kinase levels was required . Because most muscle problems do not involve an increase in creatine kinase levels , this leads to a significant underestimate of muscle problems . Other studies have estimated that closer to 20 % of statin users have muscle problems.8 Additionally , the actual trial data are largely held by the Cholesterol Treatment Trialists ’ Collaboration on behalf of the industry sponsor and have not been made available to other research ers , despite multiple requests over many years.9 Although reported rates of adverse events in clinical trials are low , this does not reflect the experience of clinicians who see patients who are taking statins . For instance , the experience of an NPR reporter with a calculated 2.9 % risk of heart disease over 10 years using the recommended American College of Cardiology/American Heart Association ( ACC/AHA ) risk calculator,10 but still prescribed a statin , and experiencing adverse effects from the medication , is typical of what many Related articles at jama.com Background Earlier diagnosis followed by multi-factorial cardiovascular risk intervention may improve outcomes in Type 2 Diabetes Mellitus ( T2DM ) . Latent phase identification through screening requires structured , appropriately targeted population -based approaches . Providers responsible for implementing screening policy await evidence of clinical and cost effectiveness from r and omised intervention trials in screen-detected T2DM cases . UK South Asians are at particularly high risk of abnormal glucose tolerance and T2DM . To be effective national screening programmes must achieve good coverage across the population by identifying barriers to the detection of disease and adapting to the delivery of earlier care . Here we describe the rationale and methods of a systematic community screening programme and r and omised controlled trial of cardiovascular risk management within a UK multiethnic setting ( ADDITION-Leicester ) . Design A single-blind cluster r and omised , parallel group trial among people with screen-detected T2DM comparing a protocol driven intensive multi-factorial treatment with conventional care . Methods ADDITION-Leicester consists of community-based screening and intervention phases within 20 general practice s coordinated from a single academic research centre . Screening adopts a universal diagnostic approach via repeated 75g-Oral Glucose Tolerance Tests within an eligible non-diabetic population of 66,320 individuals aged 40 - 75 years ( 25 - 75 years South Asian ) . Volunteers also provide detailed medical and family histories ; complete health question naires , undergo anthropometric measures , lipid profiling and a proteinuria assessment . Primary outcome is reduction in modelled Coronary Heart Disease ( UKPDS CHD ) risk at five years .  Seven thous and ( 30 % of South Asian ethnic origin ) volunteers over three years will be recruited to identify a screen-detected T2DM cohort ( n = 285 ) powered to detected a 6 % relative difference ( 80 % power , alpha 0.05 ) between treatment groups at one year . R and omisation will occur at practice -level with newly diagnosed T2DM cases receiving either conventional ( according to current national guidelines ) or intensive ( algorithmic target-driven multi-factorial cardiovascular risk intervention ) treatments . Discussion ADDITION-Leicester is the largest multiethnic ( targeting > 30 % South Asian recruitment ) community T2DM and vascular risk screening programme in the UK . By assessing feasibility and efficacy of T2DM screening , it will inform national disease prevention policy and contribute significantly to our underst and ing of the health care needs of UK South Asians . Trial registration Clinical trial.gov ( NCT00318032 ) INTRODUCTION Atrial fibrillation ( AF ) is an important independent risk factor for stroke and oral anticoagulation therapy provides a highly effective treatment to reduce this risk . Active screening strategies improve detection of AF in comparison with routine care ; however , whether screen-detected patients have stroke risk profiles favouring anticoagulation is unclear . Using data derived from the screening for AF in the elderly ( SAFE ) study , the aim of this article was to determine if patients with AF detected via active screening  have stroke risk profiles that warrant prophylactic anticoagulation . METHODS Secondary analysis of data derived from 25 general practice s within which cohorts of 200 patients were r and omly allocated to opportunistic [ pulse and electrocardiogram ( ECG ) ] or systematic screening ( postal invitation for ECG ) .  Stroke risk assessment was undertaken using baseline data extracted from medical records and CHADS2 criteria . CHADS2 scores were compared between the screening groups . RESULTS One hundred and forty-nine new cases of AF were detected , 75 via opportunistic screening and 74 via systematic screening . CHADS2 scores were ≥1 in 83 % [ 95 % confidence interval ( CI ) 72.6 - 89.6 ] of patients detected via opportunistic screening and 78 % ( 95 % CI 67.7 - 86.2 ) detected via systematic screening . There were no significant differences in stroke risk profiles of patients detected via opportunistic and systematic screenings . CONCLUSION Stroke risk profiles of patients detected via opportunistic and systematic screenings were similar . Data derived from the SAFE study suggest that active screening for AF in patients aged ≥65 years in primary care is a useful screening programme with 78 - 83 % of patients identified eligible for anticoagulation treatment according to the CHADS2 criteria Background and objective : In Sweden , mortality from cardiovascular diseases ( CVD ) increased steadily during the 20th century and in the mid-1980s it was highest in the county of Västerbotten . Therefore , a community intervention programme was launched – the Västerbotten Intervention Programme ( VIP ) – with the aim of reducing morbidity and mortality from CVD and diabetes . Design : The VIP was first developed in the small municipality of Norsjö in 1985 . Subsequently , it was successively implemented across the county and is now integrated into ordinary primary care routines . A population -based strategy directed towards the public is combined with a strategy to reach all middle-aged persons individually at ages 40 , 50 and 60 years , by inviting them to participate in systematic risk factor screening and individual counselling about healthy lifestyle habits . Blood sample s for research purpose s are stored at the Umeå University Medical Biobank . Results : Overall , 113,203 health examinations have been conducted in the VIP and 6,500–7,000 examinations take place each year . Almost 27,000 subjects have participated twice .  Participation rates have ranged between 48 and 67 % . A dropout rate analysis in 1998 indicated only a small social selection bias . Cross-sectional , nested case-control studies and prospect i ve studies have been based on the VIP data . Linkages between the VIP and local , regional and national data bases provide opportunities for interdisciplinary research , as well as national and international collaborations on a wide range of disease outcomes . A large number of publications are based on data that are collected in the VIP , many of which also use results from analysed stored blood sample s. More than 20 PhD theses have been based primarily on the VIP data . Conclusions : The concept of the VIP , established as a collaboration between politicians and health care providers on the one h and and primary care , functioning as the operating machinery , and the public on the other , forms the basis for effective implementation and endurance over time . After more than 20 years of the VIP , there is a large comprehensive population -based data base , a stable organisation to conduct health surveys and collect data , and a solid structure to enable widespread multidisciplinary and scientific collaborations Background —Few data have evaluated physician adherence to cardiovascular disease ( CVD ) prevention guidelines according to physician specialty or patient characteristics , particularly gender . Methods and Results —An online study of 500 r and omly selected physicians ( 300 primary care physicians , 100 obstetricians/gynecologists , and 100 cardiologists ) used a st and ardized question naire to assess awareness of , adoption of , and barriers to national CVD prevention guidelines by specialty . An experimental case study design tested physician accuracy and determinants of CVD risk level assignment and application of guidelines among high- , intermediate- , or low-risk patients . Intermediate-risk women , as assessed by the Framingham risk score , were significantly more likely to be assigned to a lower-risk category by primary care physicians than men with identical risk profiles ( P<0.0001 ) , and trends were similar for obstetricians/gynecologists and cardiologists . Assignment of risk level significantly predicted recommendations for lifestyle  and preventive pharmacotherapy . After adjustment for risk assignment , the impact of patient gender on preventive care was not significant except for less aspirin ( P<0.01 ) and more weight management recommended ( P<0.04 ) for intermediate-risk women . Physicians did not rate themselves as very effective in their ability to help patients prevent CVD . Fewer than 1 in 5 physicians knew that more women than men die each year from CVD . Conclusions —Perception of risk was the primary factor associated with CVD preventive recommendations . Gender disparities in recommendations for preventive therapy were explained largely by the lower perceived risk despite similar calculated risk for women versus men . Educational interventions for physicians are needed to improve the quality of CVD preventive care and lower morbidity and mortality from CVD for men and women AIMS Cardiovascular disease ( CVD ) is the leading cause of morbidity and mortality in people with diabetes in South Asia . The CARRS Translation Trial tests the effectiveness , cost-effectiveness , and sustainability of a clinic-based multi-component CVD risk reduction intervention among people with diabetes in India and Pakistan . METHODS We r and omly assigned 1146 adults with diabetes recruited from 10 urban clinic sites , to receive usual care by physicians or to receive an integrated multi-component CVD risk reduction intervention . The intervention involves electronic health record management , decision-support prompts to the healthcare team , and the support of a care coordinator to actively facilitate patient and provider adherence to evidence -based guidelines . The primary outcome is a composite of multiple CVD risk factor control ( blood glucose and either blood pressure or cholesterol , or all three ) . Other outcomes include control of the individual CVD risk factors , process and patient-centered measures , cost-effectiveness , and acceptability/feasibility . CONCLUSION The CARRS Translation Trial tests a low-cost diabetes care delivery model in urban South Asia to achieve comprehensive cardio-metabolic disease case-management of high-risk patients ( clinical trials.gov number : NCT01212328 ) Objectives To assess the effect of a point of care ( POC ) device for testing lipids  and HbA1c in addition to testing by community laboratory facilities ( usual practice ) on the completion of cardiovascular disease ( CVD ) risk assessment s in general practice . Methods We conducted a pragmatic , cluster r and omised controlled trial in 20 New Zeal and general practice s stratified by size and rurality and r and omised to POC device plus usual practice or usual practice alone ( controls ) . Patients aged 35–79 years were eligible if they met national guideline criteria for CVD risk assessment . Data on CVD risk assessment s were aggregated using a web-based decision support programme common to each practice . Data entered into the on-line CVD risk assessment form could be saved pending blood test results . The primary outcome was the proportion of completed CVD risk assessment s. Qualitative data on practice processes for CVD risk assessment and feasibility of POC testing were collected at the end of the study by interviews and question naire . The POC testing was supported by a comprehensive quality assurance programme . Results A CVD risk assessment entry was recorded for 7421 patients in 10 POC practice s and 6217 patients in 10 control practice s ; 99.5 % of CVD risk assessment s had complete data in both groups ( adjusted odds ratio 1.02 [ 95%CI 0.61–1.69 ] ) . There were major external influences that affected the trial : including a national performance target for CVD risk assessment and changes to CVD guidelines . All practice s had invested in systems and dedicated staff time to identify and follow up patients to completion . However , the POC device was viewed by most as an additional tool rather than as an opportunity to review practice work flow and leverage the immediate test results for patient education and CVD risk management discussion s. Shortly after commencement , the trial was halted due to a change in the HbA1c test assay performance . The trial restarted after the manufacturing issue was rectified but this affected the end use of the device . Conclusions Performance incentives and external influences were more powerful modifiers of practice behaviours than the POC device in relation to CVD risk assessment completion . The promise of combining risk assessment , communication and management within one consultation was not realised . With shifts in policy focus , the utility of POC devices for patient engagement in CVD preventive care may be demonstrated if fully integrated into the clinical setting . Trial registration Australian New Zeal and Clinical Trials Registry Background Intensive lifestyle interventions in well-controlled setting s are effective in lowering the risk of chronic diseases such as type 2 diabetes ( T2DM ) and cardiovascular diseases ( CVD ) , but there are still no effective lifestyle interventions for everyday practice . In the Hoorn Prevention Study we aim ed to assess the effectiveness of a primary care based lifestyle intervention to reduce the estimated risk of developing T2DM and for CVD mortality , and to motivate changes in lifestyle behaviors . Methods The Hoorn Prevention Study is a parallel group r and omized controlled trial , implemented in the region of West-Friesl and , the Netherl and s. 622 adults with ≥10 % estimated risk of T2DM and /or CVD mortality were r and omly assigned and monitored over a period of 12 months . The intervention group ( n=314 ) received a theory-based lifestyle intervention based on an innovative combination of motivational interviewing and problem solving treatment , provided by trained practice nurses in 12 general practice s. The control group ( n=308 ) received existing health brochures . Primary outcomes was the estimated diabetes risk according to the formula of the Atherosclerosis Risk In Communities ( ARIC ) Study , and the estimated risk for CVD mortality according to the Systematic COronary Risk Evaluation ( SCORE ) formula . Secondary outcomes included lifestyle behavior ( diet , physical activity and smoking ) . The research assistants , the principal investigator and the general practitioners were blinded to group assignment . Linear and logistic regression analysis was applied to examine the between-group differences in each outcome measure , adjusted for baseline values . Results 536 ( 86.2 % ) of the 622 participants ( age 43.5 years ) completed the 6-month follow-up , and 502 ( 81.2 % ) completed the 12-month follow-up . The mean baseline T2DM risk was 18.9 % ( SD 8.2 ) and the mean CVD mortality risk was 3.8 % ( SD 3.0 ) . The intervention group participated in a median of 2 sessions . Intention-to-treat analyses showed no significant differences in outcomes between the two groups at 6 or 12-months follow-up . Conclusions The lifestyle intervention was not more effective than health brochures in reducing risk scores for T2DM and CVD or improving lifestyle behavior in an at-risk population .Trial registration Current Controlled Trials : IS RCT Background The gap between the level of care recommended by evidence -based clinical practice guidelines and the actual care delivered to patients in practice has been well established . The Canadian Diabetes Association ( CDA ) created an implementation strategy to improve the implementation of its 2008 guidelines . This study will evaluate the impact of the strategy to improve cardiovascular disease ( CVD ) screening , prevention and treatment for people with diabetes . Design A pragmatic cluster-r and omized trial will be conducted to evaluate the CDA 's CVD Toolkit .  All family physicians in Ontario , Canada were r and omly allocated to receive the Toolkit , which includes several printed educational material s targeting CVD screening , prevention and treatment , either in spring 2009 ( intervention arm ) or in spring 2010 ( control arm ) . R and omization occurred at the level of the practice . Forty family physicians from each arm will be recruited to participate , and the medical records for 20 of their diabetic patients at high risk for CVD will be retrospectively review ed . Outcome measures will be assessed for each patient between July 2009 and March 2010 . The primary outcome will be that the patient is receiving a statin .  Secondary outcomes will include 1 ) the receipt of an angiotensin converting enzyme inhibitor or angiotensin receptor blocker , 2 ) various intermediate measures ( A1c , blood pressure , LDL-cholesterol , total-/HDL-cholesterol ratio , body mass index and waist circumference ) , and 3 ) clinical inertia ( the failure to change therapy in response to an abnormal A1c , blood pressure or cholesterol reading ) . The analysis will be carried out using multilevel hierarchical logistic regression models to account for the clustered nature of the data . The group assignment will be a physician-level variable . In addition , a process evaluation study with six focus groups of family physicians will assess the acceptability of the CDA 's Toolkit and will explore factors contributing to any change or lack of change in behaviour , from the perspectives of family physicians . Discussion Printed educational material s for physicians have been shown to exert small-to-moderate changes in patient care . The CDA 's CVD Toolkit is an example of a practice guideline implementation strategy that can be disseminated to a wide audience relatively inexpensively , and so demonstrating its effectiveness at improving diabetes care could have important consequences for guideline developers , policy makers and clinicians . Trial Registration The trial is registered with http://www . clinical trials.gov , ID # AIMS To estimate the potential effectiveness of different " high-risk " and " population " approaches to the primary prevention of  cardiovascular disease ( CVD ) in middle-aged British men , after correction for regression dilution bias . METHODS AND RESULTS We used a combination of cohort and r and omised controlled trial evidence to estimate the effectiveness of high-risk strategies , based on the identification of high-risk factors or high absolute risk , and strategies based on population -wide reductions in cholesterol and blood pressure . High-risk strategies were potentially effective but would need to be used widely to have a substantial effect on CVD in the population . Aggressive pharmacological treatment ( using statins , beta-blockers , ACE-inhibitors and aspirin ) in individuals with a 10-year Framingham event risk of > or=30 % ( 6 % of population ) would have reduced major CVD by at most 11 % . This figure increased to 34 % at a > or=20 % treatment threshold ( 26 % of population ) . In contrast , modest downwards shifts in the population distributions of serum total cholesterol and systolic blood pressure led to marked expected reductions in major CVD . Taking regression dilution bias into account , 10 % reductions in long-term mean blood cholesterol and blood pressure could have reduced major CVD by 45 % . CONCLUSIONS If high-risk strategies are to have a major impact on CVD in the population , they need to be more widely used than previously envisaged . Population -wide reduction of major risk factors is needed if CVD is to be substantially reduced Background Cardiovascular disease ( CVD ) is a major cause of death in China . Despite government efforts , the majority of hypertensive and diabetic patients in China do not receive proper treatment . Reducing CVD events requires long-term care that is proactive , patient-centred , community-based , and sustainable . We have design ed a package of interventions for patients at high risk of CVD to be implemented by family doctors based in township hospitals ( providers of primary care ) in rural Zhejiang , China . This trial aims to determine whether the systematic CVD risk reduction package results in reduced CVD events among patients at risk of CVD compared with usual care , and whether the package is cost-effective and suitable for routine implementation and scale-up . Methods / Design This is a prospect i ve , open-label , cluster r and omized controlled trial ( RCT ) with blinded data analysis . The trial will r and omize 67 township hospitals with 31,708 participants in three counties in Zhejiang Province . Participants will be identified from existing health records and will comprise adults aged 50 to 74 years , with a calculated 10-year CVD risk of 20 % or higher , or diabetes . In the intervention arm , participants will receive a package of interventions including : 1 ) healthy lifestyle counseling ( smoking cessation , and salt , oil , and alcohol reduction ) ; 2 ) prescription of a combination of drugs ( antihypertensives , aspirin , and statin ) ; and 3 ) adherence support for drug compliance and healthy lifestyle change . In the control arm , participants will receive usual care for hypertension and diabetes management at individual clinicians ’ discretion . The primary outcome is the incidence of severe CVD events over 24 months of follow-up . All CVD events will be defined according to the World Health Organization ( WHO ) monitoring of trends and determinants in cardiovascular disease ( MONICA ) definitions , diagnosed at the county hospital or higher level , and reported by the Zhejiang surveillance system . Secondary outcomes include : mean systolic and diastolic blood pressure , blood glucose , serum total cholesterol ( TC ) , and adherence to appointments , and drugs and lifestyle changes . Discussion This trial focuses on risk reduction of CVD rather than specific diseases . It is not design ed to compare therapeutic and healthy lifestyle interventions , but rather their combined effects in primary care setting s. Through the trial , we intend to underst and the effectiveness of the comprehensive CVD reduction package in routine practice . We also intend to underst and the barriers and facilitators to implementing the package , and thus to advise on policy and practice change . Trial registration Current Controlled Trials : IS RCT Context In 2003 , the U.S. Preventive Services Task Force recommended screening for type 2 diabetes in adults with hypertension or hyperlipidemia . The economic implication s of this recommendation are unclear . Contribution Diabetes screening for 55-year-old hypertensive persons would cost the U.S. health care system $ 34 375 per quality -adjusted life-year gained . Exp and ing screening to all adults regardless of the presence of hypertension would cost an additional $ 360 966 per quality -adjusted life-year . Implication s The cost-effectiveness of targeting diabetes screening to hypertensive adults older than 55 years of age is similar to the cost-effectiveness of many accepted health care interventions . Universal diabetes screening is far more costly . The Editors Although many adults who meet criteria for type 2 diabetes ( hereafter , diabetes ) have not been identified ( 1 ) , screening for diabetes remains controversial ( 2 - 11 ) . Direct evidence indicates that various treatments to reduce complications are effective among people with clinical ly detected diabetes ( 12 - 14 ) , but no direct evidence tells us the magnitude of any further benefit from starting these treatments earlier , after detection by screening ( 15 ) . In the absence of direct evidence , research ers have applied mathematical models of diabetes progression to the issue of screening . One analysis found that the cost per quality -adjusted life-year ( QALY ) gained by universal diabetes screening was lower for younger than for older people : $ 13 376 at age 25 to 34 years , increasing to $ 116 908 at age 55 to 64 years ( 16 ) . This conclusion followed from the model 's focus on the provision of glycemic control after screening to prevent microvascular complications . The analysis did not consider treatments to reduce the risks for complications of cardiovascular disease ( CVD ) . More recent research suggests that the benefits of CVD risk reduction may be substantial for people with diabetes . The Hypertension Optimal Treatment ( HOT ) trial found that the optimal blood pressure target is lower for people with hypertension and diabetes than for people with hypertension without diabetes ( 14 ) . Other research supports the finding that intensive control of hypertension is beneficial among people with diabetes ( 15 , 17 - 19 ) . Because the benefit may be greater for older people ( at greater risk for CVD ) , the conclusion of the previous analysis , that diabetes screening is most cost-effective among younger people , needs to be reconsidered . We performed a new cost-effectiveness analysis to compare universal diabetes screening ( universal screening ) and diabetes screening targeted to  patients with hypertension ( targeted screening ) . When an up date d version of the model used in the previous analysis that includes benefits from intensive treatment of hypertension was applied , we estimated the incremental cost-effectiveness of these 2 strategies for people in different age groups . Our analysis considers a one-time opportunistic screening for men and women of all races and ethnicities . Methods The Model We used a Markov model of diabetes disease progression to simulate lifetime diabetes-related health care costs and QALYs for people with diabetes ( Appendix Figure 1 ) . Demographic characteristics of the simulated cohort are based on 1997 population estimates projected from the 1990 U.S. Census and data on the distribution of people with diabetes by hypertension , cholesterol level , and smoking status ( 20 ) . As people progress through the simulation model from the onset of diabetes to death , they can develop 5 types of complications : nephropathy , neuropathy , retinopathy , coronary heart disease ( CHD ) , and stroke . People can die of some of these complications or of other causes . The model includes transition probabilities between disease stages on each of the 5 complication paths . The basic model structure has been described previously ( 16 , 21 ) . Key model parameters are presented in the Appendix Tables 1 to 10 . To incorporate screening into the model , we first added a screening module in which some patients with diabetes are identified earlier than they would usually have been in the absence of screening . Second , we made assumptions about the transition probabilities between disease stages from the onset of diabetes to the time of usual clinical diagnosis of diabetes on the basis of the knowledge that progression is relatively slow during this period ( 15 ) . After clinical diagnosis , disease progression depends on the number of years after normal diagnosis . Screening allows for earlier diagnosis , which in turn allows for earlier treatment interventions , such as intensive glycemic control and intensive hypertension control . These interventions decrease the transition probabilities , thereby delaying or preventing progression to diabetes complications . Costs are incurred for screening and diagnostic testing ; st and ard glycemic control and , if the person is hypertensive , st and ard hypertension control ; interventions ( intensive glycemic control and , if the person is hypertensive , intensive hypertension control ) ; and complications over the remaining lifetime of each person with diabetes . The sum of these costs and the model 's estimate of the expected QALYs for each screening strategy are used to calculate the incremental cost-effectiveness ratio of screening relative to no screening . We discounted future costs and QALYs at a 3 % annual rate . Costs are measured in 1997 U.S. dollars . Interventions We assumed that , in the absence of screening , diabetes would be diagnosed 10 years after its onset ( 15 ) . With one-time opportunistic screening , diabetes would be diagnosed on average 5 years after onset and therefore patients would begin treatment 5 years earlier . After diabetes diagnosis , all patients are treated with intensive glycemic control and , if they have hypertension , with intensive hypertension control . With targeted screening , only people with hypertension are screened . Those who screen positive and receive a diagnosis of diabetes begin intensive glycemic control and intensive hypertensive control 5 years earlier than they would in the absence of screening . With universal screening , all people , regardless of hypertension status , are screened . Those who screen positive and receive a diagnosis of diabetes begin intensive glycemic control 5 years earlier than in the absence of screening and begin intensive hypertension control 5 years earlier if they have hypertension . We defined hypertension as a blood pressure of 140/90 mm Hg or higher . We assumed that 19 % of people age 25 to 44 years , 47 % of people age 45 to 64 years , and 60 % of people age 65 to 74 years had hypertension and therefore were included in targeted screening ( 20 ) . Treatment of hypertension is modeled as st and ard ( with a target diastolic blood pressure of 90 mm Hg ) or intensive ( with a target diastolic blood pressure of 80 mm Hg ) , as in the HOT trial ( 14 ) . All persons with hypertension receive st and ard hypertension treatment until they receive a diagnosis of diabetes , after which they receive intensive hypertension treatment . The incremental cost of intensive hypertension control relative to st and ard control is $ 149 per year . In the HOT trial , the relative risk reduction for CHD events ( fatal and nonfatal myocardial infa rct ion ) was 51 % , and the relative risk reduction for stroke was about 30 % . Although neither of these separate relative risk reductions was statistically significant , the relative risk reduction ( 51 % ) for the aggregate outcome of major CVD events was statistically significant ( P = 0.005 ) . We initially modeled the relative risk reduction for CHD events for intensive hypertension control to be 51 % , with no risk reduction for stroke . We conducted a sensitivity analysis that included a 30 % relative risk reduction for stroke on the basis of other studies showing that intensive hypertension control reduces risk among people with diabetes ( 17 , 19 ) . Model estimates of the effects of glycemic control are based on the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) , a 10-year r and omized , controlled trial of intensive versus conventional glycemic control ( 12 ) . On the basis of the UKPDS , the reduction in hemoglobin A1c from intensive glycemic treatment is modeled as slowing the progression of microvascular complications ( 12 ) . The incremental cost of intensive glycemic control ( relative to st and ard control ) ranges from $ 900 to $ 1100 per year , depending on the number of years since diagnosis . Screening and Diagnostic Tests The Figure illustrates the screening and diagnostic testing process and shows where costs are incurred . Figure . Progression of persons screened for diabetes . Appendix Figure 1 . Markov model of diabetes disease progression . LEA CA MI Screening Tests We assume a one-time opportunistic screening during a regularly scheduled physician office visit . The model assumes screening by a fasting capillary blood glucose ( CBG ) test ( 22 ) and an extra 10 minutes over the usual 15 minutes for the physician visit , incurring a cost of $ 24.40 per person screened . Costs for the CBG test are derived from the Medicare Clinical Diagnostic Laboratory Fee Schedule ( 23 ) ; physician visit costs are derived from Relative Values for Physicians ( 24 ) . Table 1 shows prevalence ( from the National Health and Nutrition Examination Survey III data tape ) , CBG sensitivity and specificity values ( 22 ) with exact data points clarified via personal communication ( Rolka DB , 18 January 2002 ) , and the number needed to screen to detect one previously undiagnosed person with diabetes by sex , hypertension status , and age . Table 1 . Number of Screenings and Diagnostic Tests  Needed To Identify One Undiagnosed Diabetes Case Diagnostic Tests All people who screen ( true or false ) positive receive a diagnostic test , the fasting plasma glucose test , which is repeated if the result is positive . Because 2 consecutive elevated fasting plasma glucose test results define diabetes ( 11 ) , we assume Background NHS Health Check is a primary prevention programme offering cardiovascular disease ( CVD ) risk assessment to adults in Engl and aged 40–74 . Uptake remains a challenge and invitation method is a strong predictor of uptake . There is evidence of low uptake when using invitation letters . Telephone invitations might increase uptake , but are not widely used . We explored the potential to improve uptake through personalising letters to patient ’s CVD risk , and to compare this with generic letters and telephone invitations . Methods HEalth Check TRial ( HECTR ) was a three-arm r and omised controlled trial in nine general practice s in Staffordshire ( UK ) . Eligible patients were r and omised to be invited to a NHS Health Check using one of three methods : st and ard letter ( control ) ; telephone invitation ; letter personalised to the patient ’s CVD risk . The primary outcome was attendance/non-attendance . Data were collected on a range of patient- and practice -level factors ( e.g. , patient socio-demographics , CVD risk , practice size , Health Checks outside usual working hours ) . Multi-level logistic regression estimated the marginal effects to explore whether invitation method predicted attendance . Invitation costs were collated from practice s to estimate cost benefit . Results In total , 4614 patients were included in analysis ( mean age 50.2 ± 8.0 yr . ; 52.4 % female ) . Compared with patients invited by st and ard letter ( 30.9 % ) , uptake was significantly higher in those invited by telephone ( 47.6 % , P < .001 ) , but not personalised letter ( 31.3 % , p = .812 ) . In multi-level analysis , compared with the st and ard letter arm , likelihood of attendance was 18 percentage points higher in the telephone arm and 4 percentage points higher in the personalised letter arm . The effect of telephone calls appeared strongest in patients who were younger and had lower CVD risk . We estimated per 1000 patients invited , risk-personalised letters could result in 40 additional attended Health Checks ( at no extra cost ) and telephone invitations could result in 180 additional Health Checks at an additional cost of £ 240 . Conclusions Telephone invitations should be advocated to address the substantial deficit between current and required levels of NHS uptake , and could be targeted at younger and lower CVD risk adults .  Risk-personalised letters should be explored further in a larger sample of high risk individuals . Trial registration Registration number : IS RCT N15840751 date of registration : 24/10/2017 BACKGROUND Developing countries are experiencing increasing levels of cardiovascular disease ( CVD ) . Although there is a good underst and ing of how to deliver CVD prevention programs in developed countries , there are few data regarding strategies for CVD prevention in re source -poor setting s. This study aim ed to implement and evaluate a CVD prevention program in a rural area of India . METHODS The 2 strategies of CVD prevention to be investigated are an algorithm-based care approach and a health-promotion campaign . A factorial , cluster-r and omized trial design will be used to evaluate these , in which villages will be exposed to one , both , or neither of the interventions for a period of about 12 months . Surveys of households in every village will be used to assess outcomes in all high-risk individuals and a sample of the general adult population . RESULTS The primary outcome of the algorithm-based component of this study will be the percentage of high-risk individuals that have been " identified"-defined as having received a cardiovascular-risk assessment in the last 12 months . The primary outcome for the health-promotion component will be the percentage of the adult population with correct knowledge about the effects of 6 behavioral determinants of cardiovascular risk ( green-leafy vegetables , fruits , oily foods , salt , smoking , physical activity ) . Secondary outcomes include a range of measures defining uptake of different preventive strategies . CONCLUSIONS This study will provide evidence about the effectiveness of a simple practical mechanism of CVD preventive care specifically design ed for delivery in a re source -poor area in India Background Decreasing salt consumption can prevent cardiovascular diseases ( CVD ) . Practically , it is difficult to promote people ’s awareness of daily salt intake and to change their eating habits in terms of reducing salt intake for better cardiovascular health . Health education programs visualizing daily dietary salt content and intake may promote lifestyle changes in patients at high risk of cardiovascular diseases . Methods / Design This is a cluster r and omized trial . A total of 800 high-CVD-risk patients attending diabetes and hypertension clinics at health centers in Muang District , Chiang Rai province , Thail and , will be studied with informed consent . A health center recruiting 100 participants is a cluster , the unit of r and omization . Eight clusters will be r and omized into intervention and control arms and followed up for 1 year . Within the intervention clusters the following will be undertaken : ( 1 )  salt content in the daily diet will be measured and shown to study participants ; ( 2 )  24-hour salt intake will be estimated in overnight-collected urine and the results shown to the participants ; ( 3 ) a dietician will assist small group health education classes in cooking meals with less salt . The primary outcome is blood pressure change at the 1-year follow-up . Secondary outcomes at the 1-year follow-up are estimated 24-hoursalt intake , incidence of CVD events and CVD death . The intention-to-treat analysis will be followed . Blood pressure and estimated 24-hour salt intake will be compared between intervention and control groups at the cluster and individual level at the 1-year follow-up . Clinical CVD events and deaths will be analyzed by time-event analysis . Retinal blood vessel calibers of CVD-risk patients will be assessed cross-sectionally . Behavioral change to reduce salt intake and the influencing factors will be determined by structured equation model ( SEM ) . Multilevel regression analyses will be applied . Finally , the cost effectiveness of the intervention will be analyzed . Discussion This study is unique as it will recruit the individuals most vulnerable to CVD morbidity and mortality by applying the general Framingham CVD risk scoring system . Dietary salt reduction will be applied as a prioritized , community level intervention for the prevention of CVD in a developing country . Trial registration IS RCT Elevated blood pressure ( BP ) is a causal risk factor for cardiovascular disease ( CVD ) . Epidemiological analyses have established the grade d and continuous association between higher BP and CVD . Moreover , r and omized clinical trials among individuals with hypertension have demonstrated , in aggregate , a reduction in CVD events by 20 % , coronary heart disease ( CHD ) by 17 % , stroke by 27 % , and heart failure by 28 % for every 10 mm Hg systolic BP ( SBP ) lowering with medical therapy.1 Therefore , prevention , detection , treatment , and control of elevated BP , and its clinical correlate hypertension , is an important public health priority and a primary target for CVD prevention . Although national health surveys have demonstrated improvements in hypertension awareness and treatment , strategic opportunities to improve the efficiency and efficacy of applying BP-lowering therapy in patients most likely to benefit remain.2 Global CVD risk assessment , using multivariable prediction models that estimate absolute CVD risk from routinely measured clinical variables , has been promulgated in several CVD prevention guidelines for cholesterol management to target the most intensive preventive therapies to those at highest absolute CVD risk.3–5 Hypertension guidelines , however , have instead relied solely on isolated BP thresholds and BP goals to guide treatment initiation and intensity . In this review , we provide a rationale for incorporating global CVD risk assessment in BP treatment decision-making and propose a framework to guide its implementation in future CVD prevention guidelines . Epidemiological analyses have firmly established that CVD is a multifactorial condition and that modest increases of several CVD risk factors can often lead to greater overall risk than a severe elevation of a Background Cost-effectiveness studies of lifestyle interventions in people at risk for lifestyle-related diseases , addressing ‘ real-world ’ implementation , are needed . This study examines the cost-effectiveness of a primary care intervention from a societal perspective , compared with provision of health brochures , alongside a r and omized controlled trial . Methods Adults aged 30 - 50 years , at risk of type 2 diabetes ( T2DM ) and /or cardiovascular disease ( CVD ) , were recruited from twelve general practice s in The Netherl and s. They were r and omized to the intervention ( n = 314 ) or control group ( n = 308 ) . The intervention consisted of up to six face-to-face counseling sessions with a trained practice nurse , followed by three-monthly sessions by phone . Costs were collected using three-monthly retrospective question naires . Quality of life was measured with the EuroQol-5D-3L , at baseline , 6 , 12 and 24 months . Nine-year risk of developing T2DM and ten-year risk of CVD mortality were estimated using the ARIC and SCORE formulae , respectively , based on measurements at baseline and 24 months while applying a fixed age of 60 years at both time points . Results Small , statistically non-significant differences in effects were found between the intervention and control group with regard to risk scores and Quality Adjusted Life Years ( QALYs ) gained . The mean difference in costs between the intervention and control group was € -866 ( 95 % confidence interval -2372 ; 370 ) . The probability that the intervention was cost-effective varied from 93 % at € 8000/QALY to 88 % at € 80,000/QALY . Conclusion A primary care lifestyle intervention aim ed at adults at increased risk of T2DM and /or CVD  could result in cost savings over a two-year period . However , due to method ological uncertainty no advice can be given regarding the implementation of the intervention in Dutch general practice s . Trial registration Current Controlled Trials IS RCT N59358434 AIM To assess benefit versus harm of aspirin for cardiovascular disease ( CVD ) primary prevention by age group , gender and risk category and to interpret these results in light of current New Zeal and CVD risk assessment and management guidelines . METHODS Rates of benefit ( avoided vascular events ) and harm ( additional major extracranial bleeds ) for each gender and age group were calculated from data from the six r and omised controlled trials included in the Anti-Thrombotic Trialists ' ( ATT ) Collaboration meta- analysis . These rates were applied to CVD risk categories to calculate the net benefit or net harm likely to occur from the use of aspirin in primary prevention of CVD as monotherapy and when added to lipid and blood pressure-loweringtherapies . RESULTS Benefits of aspirin monotherapy outweigh the harms for both men and women aged up to 80 years with calculated five-year CVD risk > 15 % in primary prevention . Harm may outweigh benefit for primary prevention for those over 80 years . For men 70 - 79 years the benefit of aspirin in primary prevention is marginal when added to lipid and blood pressure-lowering therapies . DISCUSSION The recent ATT Collaboration meta- analysis has raised doubts about the relative safety of aspirin in primary prevention of CVD . However , modelling by risk category and age group suggests that current guidelines are justified in recommending aspirin for primary prevention of CVD in those with five-year CVD risk > or = 15 % up to the age of 80 years . For men 70 - 79 , consider lipid and blood pressure-lowering therapies first then reassess whether aspirin adds additional net benefit Background Clinical practice focuses on the primary prevention of  cardiovascular ( CV ) disease ( CVD ) through the modification and pharmacological treatment of elevated risk factors . Prediction models based on established risk factors are available for use in the primary prevention setting . However , the prevention of risk factor development through healthy lifestyle behaviors , or primordial prevention , is of paramount importance to achieve optimal population ‐wide CV health and minimize long‐term CVD risk . Methods and Results We developed a  lifestyle‐based CVD prediction model among 61 025 women in the Nurses ’ Health Study and 34 478 men in the Health Professionals Follow‐up Study , who were free of chronic disease in 1986 and followed for ≤24 years .  Lifestyle factors  were assessed by question naires in 1986 . In the derivation step , we used the Bayes Information Criterion to create parsimonious 20‐year risk prediction models among a r and om two thirds of participants in each cohort separately . The scores were vali date d in the remaining one third of participants in each cohort . Over 24 years , there were 3775 cases of CVD in women and 3506 cases in men . The Healthy Heart Score included age , smoking , body mass index , exercise , alcohol , and a composite diet score . In the validation cohort , the risk score demonstrated good discrimination ( Harrell 's C‐index , 0.72 ; 95 % confidence interval [ CI ] , 0.71 , 0.74 [ women ] ; 0.77 ; 95 % CI , 0.76 , 0.79 [ men ] ) , fit , and calibration , particularly among individuals without baseline hypertension or hypercholesterolemia . Conclusions The Healthy Heart Score accurately identifies individuals at elevated risk for CVD and may serve as an important clinical and public health screening tool for the primordial prevention of CVD Disseminating and implementing evidence -based , cardiovascular disease ( CVD ) prevention lifestyle interventions in community setting s and in ethnic minority population s is a challenge . We describe the design and methods for the South Asian Heart Lifestyle Intervention ( SAHELI ) study , a pilot study design ed to determine the feasibility and initial efficacy of a culturally-targeted , community-based lifestyle intervention to improve physical activity and diet behaviors among medically underserved South Asians ( SAs ) . Participants with at least one CVD risk factor will be r and omized to either a lifestyle intervention or a control group .  Participants in both groups will be screened in a community setting and receive a primary care referral after r and omization . Intervention participants will receive 6weeks of group classes , followed by 12weeks of individual telephone support where they will be encouraged to initiate and maintain a healthy lifestyle goal . Control participants will receive their screening results and monthly mailings on CVD prevention . Primary outcomes will be changes in moderate/vigorous physical activity and saturated fat intake between baseline , 3- , and 6-month follow-up . Secondary outcomes will be changes in weight , clinical risk factors , primary care visits , self-efficacy , and social support . This study will be one of the first to pilot-test a lifestyle intervention for SAs , one of the fastest growing racial/ethnic groups in the U.S. and one with disparate CVD risk . Results of this pilot study will provide preliminary data about the efficacy of a lifestyle intervention on CVD risk in SAs and inform community-engaged CVD prevention efforts in an increasingly diverse U.S. population
Limited data suggest that systematic risk assessment for CVD has no statistically significant effects on clinical endpoints .
There is limited evidence to suggest that CVD systematic risk assessment may have some favourable effects on cardiovascular risk factors .
BACKGROUND Screening programmes can potentially identify people at high cardiovascular risk and reduce cardiovascular disease ( CVD ) morbidity and mortality .
However , there is currently not enough evidence showing clear clinical or economic benefits of systematic screening-like programmes over the widely practised opportunistic risk assessment of CVD in primary care setting s. OBJECTIVES The primary objective of this review was to assess the effectiveness , costs and adverse effects of systematic risk assessment compared to opportunistic risk assessment for the primary prevention of CVD .