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Arriba: effects of an educational intervention on prescribing behaviour in prevention of CVD in general practice Cardiovascular Risk Factor Screening Satisfaction in the Heart of New Ulm Project The Impact of Health Behaviours on Incident Cardiovascular Disease in Europeans and South Asians – A Prospective Analysis in the UK SABRE Study The Cholesterol, Hypertension, and Glucose Education (CHANGE) study for African Americans with diabetes: study design and methodology. NHS health checks through general practice: randomised trial of population cardiovascular risk reduction 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 Methods for establishing a surveillance system for cardiovascular diseases in Indian industrial populations. Impact of Traditional and Novel Risk Factors on the Relationship Between Socioeconomic Status and Incident Cardiovascular Events Estimating the benefits of modifying risk factors of cardiovascular disease: a comparison of primary vs secondary prevention. Electronic Health Record-Based Patient Identification and Individualized Mailed Outreach for Primary Cardiovascular Disease Prevention: A Cluster Randomized Trial Longitudinal changes in diet from childhood into adulthood with respect to risk of cardiovascular diseases: The Cardiovascular Risk in Young Finns Study Cardiovascular risk factors and confounders among nondrinking and moderate-drinking U.S. adults. The Effect of How Outcomes Are Framed on Decisions about Whether to Take Antihypertensive Medication: A Randomized Trial The impact of individualised cardiovascular disease (CVD) risk estimates and lifestyle advice on physical activity in individuals at high risk of CVD: a pilot 2 × 2 factorial understanding risk trial Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients With Diabetes Mellitus. High Diet Quality Is Associated with a Lower Risk of Cardiovascular Disease and All-Cause Mortality in Older Men123 Evaluating the impact of population and high-risk strategies for the primary prevention of cardiovascular disease. Markers of inflammation and cardiovascular disease: application to clinical and public health practice: A statement for healthcare professionals from the Centers for Disease Control and Prevention and the American Heart Association. A cardiovascular disease policy model that predicts life expectancy taking into account socioeconomic deprivation A prospective study of dietary fiber intake and risk of cardiovascular disease among women. An Economic Evaluation of Four Work Site Based Cardiovascular Risk Factor Interventions C-reactive protein and risk of cardiovascular disease in men and women from the Framingham Heart Study. Quality of cardiovascular disease preventive care and physician/practice characteristics Comparison of the Framingham and Reynolds Risk Scores for Global Cardiovascular Risk Prediction in the Multiethnic Women's Health Initiative Plasma lycopene, other carotenoids, and retinol and the risk of cardiovascular disease in men. Legacy Effect of Delayed Blood Pressure-Lowering Pharmacotherapy in Middle-Aged Individuals Stratified by Absolute Cardiovascular Disease Risk: Protocol for a Systematic Review The @RISK Study: Risk communication for patients with type 2 diabetes: design of a randomised controlled trial Eight-year change in body mass index and subsequent risk of cardiovascular disease among healthy non-smoking men. Aspirin for primary prevention: yes or no? Overweight and obesity and weight change in middle aged men: impact on cardiovascular disease and diabetes Dietary Inflammatory Index Is Associated with Risk of All-Cause and Cardiovascular Disease Mortality but Not with Cancer Mortality in Middle-Aged and Older Japanese Adults. Effectiveness of a motivational interviewing intervention on weight loss, physical activity and cardiovascular disease risk factors: a randomised controlled trial with a 12-month post-intervention follow-up A trial of B vitamins and cognitive function among women at high risk of cardiovascular disease. Randomized controlled trial of cognitive behavioral therapy vs standard treatment to prevent recurrent cardiovascular events in patients with coronary heart disease: Secondary Prevention in Uppsala Primary Health Care project (SUPRIM). Cardiovascular disease, risk factors and heart rate variability in the elderly general population: Design and objectives of the CARdiovascular disease, Living and Ageing in Halle (CARLA) Study Effectiveness of the Heart Age tool for improving modifiable cardiovascular risk factors in a Southern European population: a randomized trial Leisure time physical activity and long-term cardiovascular and cancer outcomes: the Busselton Health Study Improving cardiovascular risk management: a randomized, controlled trial on the effect of a decision support tool for patients and physicians Impact of intensive lifestyle and metformin therapy on cardiovascular disease risk factors in the diabetes prevention program. Comparison of associations of adherence to a Dietary Approaches to Stop Hypertension (DASH)-style diet with risks of cardiovascular disease and venous thromboembolism. Isfahan Healthy Heart Programme: a comprehensive integrated community-based programme for cardiovascular disease prevention and control. Design, methods and initial experience Mediterranean diet score and total and cardiovascular mortality in Eastern Europe: the HAPIEE study Multiple health behaviors in an ethnically diverse sample of adults with risk factors for cardiovascular disease. A Polypill for primary prevention of cardiovascular disease: A feasibility study of the World Health Organization Strawberry Intake, Lipids, C-Reactive Protein, and the Risk of Cardiovascular Disease in Women Endogenous Sex Hormones and Cardiovascular Disease Incidence in Men Improving diabetes care: multi-component cardiovascular disease risk reduction strategies for people with diabetes in South Asia--the CARRS multi-center translation trial. Role of Time-of-Day of Hypertension Treatment on the J-Shaped Relationship Between Blood Pressure and Cardiovascular Risk The South Asian Heart Lifestyle Intervention (SAHELI) study to improve cardiovascular risk factors in a community setting: design and methods. Rice consumption and risk of cardiovascular disease: results from a pooled analysis of 3 U.S. cohorts1234 Relationship between low cardiorespiratory fitness and mortality in normal-weight, overweight, and obese men. A Markov model of the cost-effectiveness of pharmacist care for diabetes in prevention of cardiovascular diseases: evidence from Kaiser Permanente Northern California. Oxidized Phospholipids, Lipoprotein(a), Lipoprotein-Associated Phospholipase A2 Activity, and 10-Year Cardiovascular Outcomes: Prospective Results From the Bruneck Study Yoga lifestyle intervention reduces blood pressure in HIV-infected adults with cardiovascular disease risk factors. 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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 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 Background Cardiovascular disease ( CVD ) remains the leading cause of death globally . Primary prevention of CVD requires cost-effective strategies to identify individuals at high risk in order to help target preventive interventions . An integral part of this approach is the use of CVD risk scores . Limitations in previous studies have prevented reliable inference about the potential advantages and the potential harms of using CVD risk scores as part of preventive strategies . We aim to evaluate short-term effects of providing different types of information about coronary heart disease ( CHD ) risk , alongside lifestyle advice , on health-related behaviours . Methods / Design In a parallel-group , open r and omised trial , we are allocating 932 male and female blood donors with no previous history of CVD aged 40–84 years in Engl and to either no intervention ( control group ) or to one of three active intervention groups : i ) lifestyle advice only ; ii ) lifestyle advice plus information on estimated 10-year CHD risk based on phenotypic characteristics ; and iii ) lifestyle advice plus information on estimated 10-year CHD risk based on phenotypic and genetic characteristics . The primary outcome is change in objective ly measured physical activity . Secondary outcomes include : objective ly measured dietary behaviours ; cardiovascular risk factors ; current medication and healthcare usage ; perceived risk ; cognitive evaluation of provision of CHD risk scores ; and psychological outcomes . The follow-up assessment takes place 12 weeks after r and omisation . The experiences , attitudes and concerns of a subset of participants will be also studied using individual interviews and focus groups . Discussion The INFORM study has been design ed to provide robust findings about the short-term effects of providing different types of information on estimated 10-year CHD risk and lifestyle advice on health-related behaviours . Trial registration Current Controlled Trials IS RCT N17721237 . Registered 12 January 2015 A community cardiovascular disease ( CVD ) prevention programme was undertaken in 1989 in a Danish County ( Vejle ) . A r and om sample of 5192 adults were asked to complete a mailed question naire on  knowledge , attitudes , and behaviour  in relation to CVD risk factors . The response rate was 56 % . The question naire produced baseline data for programme planning and measuring the success of on-going interventions . Smoking , overweight , and unhealthy food habits were the most prevalent CVD risk factors . A CVD risk score was calculated from the data on smoking , food habits , exercise , stress , overweight , self-reported presence of hypertension , diabetes , and gender . A high score was commoner in men , in the least educated , in groups who judged their own risk as high , and in groups with negative health beliefs . The level of knowledge about CVD risk factors was high in general . Low knowledge was commonest in the youngest age group , in the least educated , in unskilled workers , and in groups with negative health beliefs . As social position and personality factors seem to play an important role in actions people may take in prevention of CVD , they should be considered in the planning of the health promotion activities in Vejle Background Cardiovascular disease ( CVD ) is the leading cause of death and disability worldwide . Despite the widespread availability of evidence -based clinical guidelines and vali date d risk predication equations for prevention and management of CVD , their translation into routine practice is limited . We developed a multifaceted quality improvement intervention for CVD risk management which incorporates electronic decision support , patient risk communication tools , computerised audit and feedback tools , and monthly , peer-ranked performance feedback via a web portal . The intervention was implemented in a cluster r and omised controlled trial in 60 primary healthcare services in Australia . Overall , there were improvements in risk factor recording and in prescribing of recommended treatments among under-treated individuals , but it is unclear how this intervention was used in practice and what factors promoted or hindered its use . This information is necessary to optimise intervention impact and maximally implement it in a post-trial context . In this study protocol , we outline our methods to conduct a theory-based , process evaluation of the intervention . Our aims are to underst and how , why , and for whom the intervention produced the observed outcomes and to develop effective strategies for translation and dissemination . Methods / Design We will conduct four discrete but inter-related studies taking a mixed methods approach . Our quantitative studies will examine ( 1 ) the longer term effectiveness of the intervention post-trial , ( 2 ) patient and health service level correlates with trial outcomes , and ( 3 ) the health economic impact of implementing the intervention at scale . The qualitative studies will ( 1 ) identify healthcare provider perspectives on implementation barriers and enablers and ( 2 ) use video ethnography and patient semi-structured interviews to underst and how cardiovascular risk is communicated in the doctor/patient interaction both with and without the use of intervention . We will also assess the costs of implementing the intervention in Australian primary healthcare setting s which will inform scale-up considerations . Discussion This mixed methods evaluation will provide a detailed underst and ing of the process of implementing a  quality improvement intervention and identify the factors that might influence scalability and sustainability . Trials registration 12611000478910 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 We conducted a feasibility study of a web-based intervention , which provided personalized cardiovascular disease ( CVD ) risk information , behavioural risk reduction strategies and educational re sources . Participants were block-r and omized to the 3-month intervention ( n = 47 ) or to usual care ( n = 49 ) . Participants in the intervention group were presented with their CVD risk based on the Framingham risk score , and in three subsequent online encounters could select two behavioural/lifestyle modules , giving them an opportunity to complete six modules over the course of the study . Because it was self-guided , participants had differing levels of engagement with intervention material s. Most intervention group participants ( 77 % , n = 36 ) completed all modules . After 3 months there were no significant differences between the intervention and usual care groups for systolic blood pressure , body-mass index , CVD risk , smoking cessation or medication non-adherence . The study suggests that modest clinical improvements can be achieved by interventions that are entirely web-administered . However , web-based interventions do not replace the need for human interaction to communicate CVD risk and assist with decision-making BACKGROUND Worldwide implementation of risk-based cardiovascular disease ( CVD ) prevention requires risk prediction tools that are contemporarily recalibrated for the target country and can be used where laboratory measurements are unavailable . We present two cardiovascular risk scores , with and without laboratory-based measurements , and the corresponding risk charts for 182 countries to predict 10-year risk of fatal and non-fatal CVD in adults aged 40 - 74 years . METHODS Based on our previous laboratory-based prediction model ( Globorisk ) , we used data from eight prospect i ve studies to estimate coefficients of the risk equations using proportional hazard regressions . The laboratory-based risk score included age , sex , smoking , blood pressure , diabetes , and total cholesterol ; in the non-laboratory ( office-based ) risk score , we replaced diabetes and total cholesterol with BMI . We recalibrated risk scores for each sex and age group in each country using country-specific mean risk factor levels and CVD rates . We used recalibrated risk scores and data from national surveys ( using data from adults aged 40 - 64 years ) to estimate the proportion of the population at different levels of CVD risk  for ten countries from different world regions as examples of the information the risk scores provide ; we applied a risk threshold for high risk of at least 10 % for high-income countries ( HICs ) and at least 20 % for low-income and middle-income countries ( LMICs ) on the basis of national and international guidelines for CVD prevention . We estimated the proportion of men and women who were similarly categorised as high risk or low risk by the two risk scores . FINDINGS Predicted risks for the same risk factor profile were generally lower in HICs than in LMICs , with the highest risks in countries in central and southeast Asia and eastern Europe , including China and Russia . In HICs , the proportion of people aged 40 - 64 years at high risk of CVD ranged from 1 % for South Korean women to 42 % for Czech men ( using a ≥10 % risk threshold ) , and in low-income countries ranged from 2 % in Ug and a ( men and women ) to 13 % in Iranian men ( using a ≥20 % risk threshold ) . More than 80 % of adults were similarly classified as low or high risk by the laboratory-based and office-based risk scores . However , the office-based model substantially underestimated the risk among patients with diabetes . INTERPRETATION Our risk charts provide risk assessment tools that are recalibrated for each country and make the estimation of CVD risk possible without using laboratory-based measurements . FUNDING National Institutes of Health 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 —In apparently healthy people , the relation between blood pressure and risk of subsequent cardiovascular disease ( CVD ) is linear . In persons with CVD , the relation is uncertain . Methods and Results —We conducted a prospect i ve study of 5218 older women with CVD who reported their blood pressure at baseline in the Women ’s Antioxidant Cardiovascular Study ( WACS ) , an ongoing double-blind , placebo-controlled secondary prevention trial of the benefits and risks of antioxidant vitamins , folic acid , vitamin B6 , and vitamin B12 among women with CVD or ≥3 coronary risk factors . A total of 661 confirmed CVD events ( nonfatal myocardial infa rct ion , nonfatal stroke , coronary artery bypass graft procedure , percutaneous coronary angioplasty , or CVD death ) occurred during a median follow-up of 6.5 years . After controlling for age , r and omized treatment assignment , antihypertensive medication use , and coronary risk factors , we found that systolic blood pressure ( SBP ) was a strong predictor of CVD events and that the relation between SBP and CVD risk was positive , continuous , and linear ( P for linear trend=0.001 ) . For each 10-mm Hg increment in SBP , there was a 9 % ( 95 % CI 4 % to 15 % ) increase in risk of secondary CVD events . Diastolic blood pressure , mean arterial pressure , and pulse pressure were weaker predictors of CVD risk in this cohort , and joint consideration of SBP and diastolic blood pressure found that only SBP significantly predicted risk . Use of antihypertensive medication did not modify the relationship of SBP with CVD events . Conclusions —In this population of women with CVD , we observed a strong , continuous , and linear association between SBP and risk of secondary CVD events . SBP was the blood pressure measure most strongly related to CVD risk 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 OBJECTIVES To evaluate a Framingham risk function for coronary heart disease in an elderly Australian cohort and to derive a risk function for cardiovascular disease ( CVD ) in elderly Australians . DESIGN AND SETTING Analysis of data from a prospect i ve cohort study ( the Dubbo Study ) in a semi-urban town ( population , 34 000 ) . PARTICIPANTS 2805 men and women 60 years and older living in the community , first assessed in 1988 , and a subcohort of 2102 free of CVD at study entry . MAIN OUTCOME MEASURES Incidence of CVD ( myocardial infa rct ion , coronary death or stroke ) over 5 and 10 years . RESULTS A Framingham risk function assessing " hard " coronary heart disease ( ie , myocardial infa rct ion or coronary death ) accurately predicted 10-year incidence in men and women aged 60 - 79 years who were free of prevalent CVD or diabetes at study entry . In a multiple logistic model , CVD incidence was significantly predicted by age , sex , taking antihypertensive medication , blood pressure , smoking , total cholesterol level and diabetes . For a given age and cholesterol level , CVD risk over 5 years was doubled in the presence of antihypertensive medication or diabetes , increased by 50 % with cigarette smoking , and halved in women compared with men . CONCLUSIONS We have derived a simple CVD risk function specifically for elderly Australians that employs risk factors readily accessible to all medical practitioners Aims /hypothesisTo determine the associations of baseline depression symptoms and use of antidepressant medicines ( ADMs ) with baseline cardiovascular disease ( CVD ) risk factors in Look AHEAD ( Action for Health in Diabetes ) trial participants . Methods Look AHEAD participants ( n = 5,145 ; age 58.7 ± 6.8 years ; BMI 35.8 ± 5.8 kg/m2 ) were assessed for CVD risk factors ( elevated HbA1c or insulin use , elevated BP or antihypertensive use , elevated lipid levels or lipid-lowering medication , current smoking , BMI ≥30 kg/m2 , lower peak exercise capacity assessed as metabolic equivalents [ METs ] , and ankle – brachial index < 0.9 or > 1.3 ) . Participants also completed the Beck Depression Inventory ( BDI ) and reported their use of ADMs . Results Of the participants , 14.7 % had BDI scores ≥11 , consistent with mild-moderate depression , and 16.5 % took ADMs ; 4.4 % had both depression markers ( i.e. elevated symptom scores and took ADMs ) . In logistic regression analyses of CVD risk ( elevated risk factor or use of medication to control the risk factor ) , controlled for demographic factors , continuous BDI  scores and ADM use were each independently associated with elevated BP ( or medication ) , current smoking , BMI ≥30 kg/m2 and lower MET values . ADM use was also associated with elevated serum lipids or use of lipid-lowering medication . Conclusions /interpretationAmong Look AHEAD participants , depression symptoms or ADM use on entry to the study were each independently associated with a wide range of CVD risk factors . Future research should assess the temporal dynamics of the relationships  of depression symptoms and ADM use with CVD risk factors . Trial registration Clinical trials.gov NCT00017953 Funding This study is funded by the National Institutes of Health with additional support from the Centers for Disease Control and Prevention 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 The objective of this study was to evaluate the effects of the ATS-Sardegna Campaign on lifestyle and cardiovascular disease ( CVD ) risk factors in the Sardinian population . The Campaign was a community-based public health action programme funded by the Sardinian Government with a view to prevent CVD and promote healthy behaviour . It was also part of the Targeted Project FAT.MA . of the Italian National Research Council ( CNR ) , with the main purpose of evaluating the effects of this public health initiative after a five- year intervention . The evaluation was effected with three parallel procedures : individual interviews with 1486 r and omly chosen people ; assessment of eating patterns through a food-frequency question  naire ; measurement of the mean levels of the major CVD risk factors in 1729 r and omly chosen subjects ( 1044 in the calendar year 1992 , and 685 in 1995 , two and five years , respectively , after the beginning of the Campaign ) . Overall , we recorded a favourable trend in eating habits in both sexes ; a significant decrease in LDL-cholesterol in males , and in systolic and diastolic blood pressure in both sexes ; a non- significant decrease in prevalence of smokers among males and increase among females . The ATS-Sardegna Campaign was the first CVD prevention programme in Italy to have attained reduction in the risk profile of an entire region at the lowest ever borne cost PURPOSE We wanted to determine the effect of promoting the effective communication of absolute cardiovascular disease ( CVD ) risk and shared decision making through disseminating a simple decision aid for use in family practice consultations . METHODS The study was based on a pragmatic , cluster r and omized controlled trial ( phase III ) with  continuing medical education ( CME ) groups of family physicians  as the unit of r and omization . In the intervention arm , 44 physicians ( 7 CME groups ) consecutively recruited 550 patients in whom cholesterol levels were measured . Forty-seven physicians in the control arm ( 7 CME groups ) similarly included 582 patients . Four hundred sixty patients ( 83.6 % ) of the intervention arm and 466 patients ( 80.1 % ) of the control arm were seen at follow-up . Physicians attended 2 interactive CME sessions and received a booklet , a paper-based risk calculator , and individual summary sheets for each patient . Control physicians attended 1 CME-session on an alternative topic . Main outcome measures were patient satisfaction and participation after the index consultation , change in CVD risk status , and decisional regret at 6 months ’ follow-up . RESULTS Intervention patients were significantly more satisfied with process and result ( Patient Participation Scale , difference 0.80 , P<.001 ) . Decisional regret was significantly lower at follow-up ( difference 3.39 , P = .02 ) . CVD risk decreased in both groups without a significant difference between study arms . CONCLUSION A simple transactional decision aid based on calculating absolute individual CVD risk and promoting shared decision making in CVD prevention can be disseminated through CME groups and may lead to higher patient satisfaction and involvement and less decisional regret , without negatively affecting global CVD risk 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 Background High blood pressure ( HBP ) is a major risk factor for cardiovascular disease ( CVD ) . European hypertension and cardiology societies as well as expert committees on CVD prevention recommend stratifying cardiovascular risk using the SCORE method , the modification of lifestyles to prevent CVD , and achieving good control over risk factors . The EDUCORE ( Education and Coronary Risk Evaluation ) project aims to determine whether the use of a cardiovascular risk visual learning method - the EDUCORE method - is more effective than normal clinical practice in improving the control of blood pressure within one year in patients with poorly controlled hypertension but no background of CVD ; Methods / Design This work describes a protocol for a clinical trial , r and omised by clusters and involving 22 primary healthcare clinics , to test the effectiveness of the EDUCORE method . The number of patients required was 736 , all between 40 and 65 years of age ( n = 368 in the EDUCORE and control groups ) , all of whom had been diagnosed with HBP at least one year ago , and all of whom had poorly controlled hypertension ( systolic blood pressure ≥ 140 mmHg and /or diastolic ≥ 90 mmHg ) . All personnel taking part were explained the trial and trained in its methodology . The EDUCORE method contemplates the visualisation of low risk SCORE scores using images embodying different stages of a high risk action , plus the receipt of a pamphlet explaining how to better maintain cardiac health . The main outcome variable was the control of blood pressure ; secondary outcome variables included the SCORE score , therapeutic compliance , quality of life , and total cholesterol level . All outcome variables were measured at the beginning of the experimental period and again at 6 and 12 months . Information on sex , age , educational level , physical activity , body mass index , consumption of medications , change of treatment and blood analysis results was also recorded ; Discussion The EDUCORE method could provide a simple , inexpensive means of improving blood pressure control , and perhaps other health problems , in the primary healthcare setting ; Trial registration The trial was registered with Clinical Trials.gov , number NCT01155973 [ http:// Clinical Trials.gov ] BACKGROUND Cardiovascular disease ( CVD ) is the leading cause of death , and principal reason for the large difference in life expectancy between indigenous Māori and the non-indigenous population in New Zeal and . CVD guidelines recommend that people who are at high risk or who have had previous CVD should be offered aspirin , blood pressure lowering and lipid lowering therapies . However , prescribing and adherence rates are low and CVD events remain high . AIM To assess whether a medication strategy using a fixed dose combination pill ( ' polypill ' ) could improve prescribing and adherence to recommended medications , lower blood pressure and improve lipids compared with current care over 12 months . METHODS IMProving Adherence using Combination Therapy ( IMPACT ) is an open-label r and omised controlled trial comparing a once-daily polypill containing four preventive medications with usual care .  Six hundred participants who have had previous CVD events or are at high risk of CVD will be enrolled , including 300 Māori . Participants are identified , enrolled and prescribed either the polypill or current medications at their usual primary health care practice , with medications ( including the polypill ) dispensed through local community pharmacies . The polypill contains 75 mg aspirin , 40 mg simvastatin , 10 mg lisinopril and either 12.5 mg hydrochlorothiazide or 50 mg atenolol . Primary outcomes are adherence to guidelines -recommended medications and changes in systolic blood pressure and low density lipoprotein at 12 months . Secondary outcomes include other lipids , medication dispensing , barriers to adherence , CVD and other serious adverse events , quality of life and prescriber acceptability . The trial is registered with the Australian New Zeal and Clinical Trial Registry ( ACTRN12606000067572 ) We assessed the importance of Streptococcus pneumoniae and immunologic response to 14-valent pneumococcal vaccine in a r and omized ( saline placebo or vaccine ) double-blind pilot study involving 103 patients with chronic obstructive pulmonary disease ( COPD ) .  Antibody titers , the flora of the sputum , respiratory infections or pneumonias , and deaths were monitored . The patients ' antibody titers before immunization were higher than healthy control subjects . Titers rose normally in those vaccinated but declined more rapidly . Differences between the group receiving placebo and vaccine were not significant at 12 and 24 months . The incidence of pneumonia was high before and after vaccine ( 47/1,000 vs 41/1,000 patient-years ) . Nonpneumococcal causes predominated ( 73 percent of pneumonias ; 83.4 percent of lethal pneumonias ) . Isolates from sputum were predominantly nonvaccine types ( 50 to 62.5 percent ) . Twenty-seven patients died ; pneumonia occurred in six ( one pneumococcal in a vaccinated patient ) as a terminal complication of other diseases . Thus , although pneumonia occurred frequently in these patients with COPD and contributed to mortality in 22 percent ( six ) of the 27 deaths , the predominance of nonpneumococcal causes and the data on antibodies and sputum suggest that pneumococcal vaccine may not be as beneficial for patients with COPD as was hoped . More observations are needed BACKGROUND The identification of persons at high cardiovascular risk is of primary importance in the context of cardiovascular prevention . Accuracy and precision of risk assessment are essential properties . We developed a calibrated SCORE risk chart ( Systematic COronary Risk Evaluation ) for calculating the absolute 10-year probability of developing a fatal cardiovascular event , adapted to national mortality statistics and risk factor distributions in Belgium and critically evaluated its predictive accuracy . METHODS Our SCORE Belgium risk chart was vali date d using data from 6212 non-diabetic men and women free of CHD participating in a prospect i ve cohort study carried out in the eighties ( Belgian Interuniversity Research on Nutrition and Health ) . Agreement between numbers of predicted and observed CVD deaths across the entire spread of risk was studied using chi-square and Hosmer-Lemeshow statistics . Discriminatory power of risk estimates was evaluated according to Harrell 's c-statistic . RESULTS During the period of 10 years , 274 CVD deaths were observed while the recalibrated risk chart predicted 263 events . The SCORE Belgium risk chart showed very good accuracy over the complete range of predicted risk ( Hosmer-Lemeshow : P=0.14 ) . ROC analysis revealed excellent discriminatory power in labelling future cases of fatal cardiovascular disease with a c-statistic of 0.86 . The 5 % threshold for the probability of 10-year cardiovascular death yielded an optimal balance of sensitivity and specificity . CONCLUSIONS The SCORE Belgium risk chart proves to be well suited as an accurate and precise estimation tool for the assessment of cardiovascular risk in Belgium BACKGROUND Despite the cardiovascular disease ( CVD ) risk associated with hypertension , diabetes , dyslipidemia , and smoking , these risk factors remain poorly identified and controlled . OBJECTIVES The study sought to evaluate the effectiveness of a community pharmacy-based case finding and intervention on cardiovascular risk . METHODS The RxEACH ( Alberta Vascular Risk Reduction Community Pharmacy Project ) study was a r and omized trial conducted in 56 community pharmacies . Participants were recruited by their pharmacist , who enrolled adults at high risk for CVD . Patients were r and omized to usual care ( usual pharmacist care with no specific intervention ) or intervention , comprising a Medication Therapy Management review from their pharmacist and CVD risk assessment and education . Pharmacists prescribed medications and ordered laboratory tests as per their scope of practice to achieve treatment targets . Subjects received monthly follow-up visits for 3 months . The primary outcome was difference in change in estimated CVD risk between groups at 3 months . CVD risk was estimated using the greater of the Framingham , International , or United Kingdom Prospect i ve Diabetes Study risk scores . RESULTS We enrolled 723 patients ( mean 62 years of age ; 58 % male , and 27 % smokers ) . After adjusting for baseline values and center effect , there was a 21 % difference in change in risk for CVD events ( p < 0.001 ) between the intervention and usual care groups . The intervention group had greater improvements in low-density lipoprotein cholesterol ( -0.2 mmol/l ; p < 0.001 ) , systolic blood pressure ( -9.37 mm Hg ; p < 0.001 ) , glycosylated hemoglobin ( -0.92 % ; p < 0.001 ) , and smoking cessation ( 20.2 % ; p = 0.002 ) . CONCLUSIONS The RxEACH study was the first large r and omized trial of CVD risk reduction by community pharmacists , demonstrating a significant reduction in risk for CVD events . Engagement of community pharmacists with an exp and ed scope of practice could have significant public health implication s. ( The Alberta Vascular Risk Reduction Community Pharmacy Project : RxEACH [ RxEACH ] ; NCT01979471 ) IMPORTANCE The value of measuring levels of glycated hemoglobin ( HbA1c ) for the prediction of first cardiovascular events is uncertain . OBJECTIVE To determine whether adding information on HbA1c values to conventional cardiovascular risk factors is associated with improvement in prediction of cardiovascular disease ( CVD ) risk . DESIGN , SETTING , AND PARTICIPANTS Analysis of individual-participant data available from 73 prospect i ve studies involving 294,998 participants without a known history of diabetes mellitus or CVD at the baseline assessment . MAIN OUTCOMES AND MEASURES Measures of risk discrimination for CVD outcomes ( eg , C-index ) and reclassification ( eg , net reclassification improvement ) of participants across predicted 10-year risk categories of low ( < 5 % ) , intermediate ( 5 % to < 7.5 % ) , and high ( ≥ 7.5 % ) risk . RESULTS During a median follow-up of 9.9 ( interquartile range , 7.6 - 13.2 ) years , 20,840 incident fatal and nonfatal CVD outcomes ( 13,237 coronary heart disease and 7603 stroke outcomes ) were recorded . In analyses adjusted for several conventional cardiovascular risk factors , there was an approximately J-shaped association between HbA1c values and CVD risk . The association between HbA1c values and CVD risk changed only slightly after adjustment for total cholesterol and triglyceride concentrations or estimated glomerular filtration rate , but this association attenuated somewhat after adjustment for concentrations of high-density lipoprotein cholesterol and C-reactive protein . The C-index for a CVD risk prediction model containing conventional cardiovascular risk factors alone was 0.7434 ( 95 % CI , 0.7350 to 0.7517 ) . The addition of information on HbA1c was associated with a C-index change of 0.0018 ( 0.0003 to 0.0033 ) and a net reclassification improvement of 0.42 ( -0.63 to 1.48 ) for the categories of predicted 10-year CVD risk . The improvement provided by HbA1c assessment in prediction of CVD risk was equal to or better than estimated improvements for measurement of fasting , r and om , or postload plasma glucose levels . CONCLUSIONS AND RELEVANCE In a study of individuals without known CVD or diabetes , additional assessment of HbA1c values in the context of CVD risk assessment provided little incremental benefit for prediction of CVD risk Introduction : A large proportion of the cardiovascular disease ( CVD ) burden can potentially be prevented by primary prevention programs addressing major causal risk factors . A Web-based health risk assessment ( HRA ) with tailored feedback for individual health promotion is a promising strategy . We evaluated the effect on CVD risk of such a program among employees of a Dutch worksite . Methods : We conducted a prospect i ve follow-up study among 368 employees who voluntarily participated in a Web-based HRA program at a single Dutch worksite in 2008 . The program included a multicomponent HRA through a Web-based electronic question naire , biometrics , and laboratory evaluation . The results were combined with health behavior change theory to generate tailored motivational and educational health advice . On request , a health counseling session with the program physician was available . Follow-up data on CVD risk were collected 1 year after initial participation . The primary outcome was a change in Framingham CVD risk at 6 months relative to baseline . We checked for a possible background effect of an increased health consciousness as a consequence of program introduction at the worksite by comparing baseline measurements of early program participants with baseline measurements of participants who completed the program 6 months later . Results : A total of 176 employees completed follow-up measurements after a mean of 7 months . There was a grade d relation between CVD risk changes and baseline risk , with a relative reduction of 17.9 % ( P = 0.001 ) in the high-risk category ( baseline CVD risk ≥20 % ) . Changes were not explained by additional health counseling , medication , or an increase in health consciousness within the company . Conclusions : Voluntary participation in a Web-based HRA with tailored feedback at the worksite reduced CVD risk by nearly 18 % among participants at high CVD risk and by nearly 5 % among all participants . Web-based HRA could improve CVD risk in similar population s. Future research should focus on the persistence of the effects underlying the CVD risk reduction Objectives In many current guidelines , blood pressure (BP)-lowering drug treatment for primary prevention of cardiovascular disease ( CVD ) is based on absolute risk . However , in clinical practice , therapeutic decisions are often based on BP levels alone . We sought to investigate which approach was superior by conducting a post hoc analysis of the Australian National Blood Pressure ( ANBP ) cohort , a seminal study establishing the efficacy of BP lowering in ‘ mild hypertensive ’ persons . Design A post hoc subgroup analysis of the ANBP trial results by baseline absolute risk tertile . Setting and participants 3244 participants aged 35–69 years in a community-based r and omised placebo controlled trial of blood pressure-lowering medication . Interventions Chlorothiazide500 mg versus placebo . Primary outcome measures All-cause mortality and non-fatal events ( non-fatal CVD , congestive cardiac failure , renal failure , hypertensive retinopathy or encephalopathy ) . Results Treatment effects were assessed by HR , absolute risk reduction and number needed to treat . Participants had an average 5-year CVD risk in the intermediate range ( 10.5±6.5 ) with moderately elevated BP ( mean 159/103 mmHg ) and were middle aged ( 52±8 years ) . In a subgroup analysis , the relative effects ( HR ) and absolute effects ( absolute risk reduction and number needed to treat ) did not statistically differ across the three risk groups except for the absolute benefit in all-cause mortality ( p for heterogeneity=0.04 ) . With respect to absolute benefit , drug treatment significantly reduced the number of events in the high-risk group regarding any event with a number needed to treat of 18 ( 10 to 64 ) , death from any cause with 45 ( 25 to 196 ) and major CVD events with 23 ( 12 to 193 ) . Conclusion Our analysis confirms that the benefit of treatment was substantial only in the high-risk tertile , reaffirming the rationale of treating elevated blood pressure in the setting of all risk factors rather than in isolation 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 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 In Europe , for primary prevention of cardiovascular diseases ( CVD ) , the Systematic COronary Risk Evaluation ( SCORE ) risk charts for high-risk and low-risk regions ( SCORE-high and SCORE-low , respectively ) are used . For the Dutch ‘ Clinical Practice Guideline for Cardiovascular Risk Management ’ an adapted SCORE risk chart ( SCORE-NL ) was developed in collaboration with the SCORE group . We evaluated these three SCORE equations using Dutch risk factor and mortality data . Design Prospect i ve cohort study with 10-year follow-up . Methods Baseline data were collected between 1987 and 1997 in 32 885 persons aged 37.5–62.5 years .  Vital status was checked and causes of death were obtained from Statistics Netherl and s. On the basis of the level of risk factors , the expected number of CVD deaths was calculated by applying the three SCORE equations and compared with the observed number . Results The observed CVD mortality was three-fold higher in men ( n = 242 ; 1.6 % ) than in women ( n = 83 ; 0.5 % ) . On the basis of SCORE-NL , 8.5 % of the men and 0.8 % of the women had a CVD mortality risk of 5 % or more . The ratio of the observed-to-expected number of CVD deaths was 0.75 for men and 0.55 for women using SCORE-NL , 0.54 and 0.56 using SCORE-high , and 1.11 and 0.95 using SCORE-low . Conclusion At the population level , SCORE-low predicts the number of CVD deaths well , whereas both SCORE-NL and SCORE-high overestimate the number of CVD deaths by a factor 1.5–2 Background Large gaps exist in the implementation of guideline recommendations for cardiovascular disease ( CVD ) risk management .  Electronic decision support ( EDS ) systems are promising interventions to close these gaps but few have undergone clinical trial evaluation in Australia . We have developed HealthTracker , a multifaceted EDS and quality improvement intervention to improve the management of CVD risk . Methods / design It is hypothesised that the use of HealthTracker over a 12-month period will result in : ( 1 ) an increased proportion of patients receiving guideline -indicated measurements of CVD risk factors and ( 2 ) an increased proportion of patients at high risk will receive guideline -indicated prescriptions for lowering their CVD risk . Sixty health services ( 40 general practice s and 20 Aboriginal Community Controlled Health Services ( ACCHSs ) will be r and omised in a 1:1 allocation to receive either the intervention package or continue with usual care , stratified by service type , size and participation in existing quality improvement initiatives . The intervention consists of point-of-care decision support ; a risk communication interface ; a clinical audit tool to assess performance on CVD-related indicators ; a quality improvement component comprising peer-ranked data feedback and support to develop strategies to improve performance .  The control arm will continue with usual care without access to these intervention components . Quantitative data will be derived from cross-sectional sample s at baseline and end of study via automated data extraction . Detailed process and economic evaluations will also be conducted . Ethics and dissemination The general practice component of the study is approved by the University of Sydney Human Research Ethics Committee ( HREC ) and the ACCHS component is approved by the Aboriginal Health and Medical Research Council HREC . Formal agreements with each of the participating sites have been signed . In addition to the usual scientific forums , results will be disseminated via newsletters , study websites , face-to-face feedback forums and workshops . Trial registration The trial is registered with the Australian Clinical Trials Registry ACTRN 12611000478910 BACKGROUND Sub clinical depression , often clinical ly unrecognized , may pose increased risk of cardiovascular disease . Few studies have prospect ively investigated cardiovascular events related to depression in older women . We describe prevalence , cardiovascular correlates , and relationship to subsequent cardiovascular events of depressive symptoms among generally healthy postmenopausal women . METHODS The Women 's Health Initiative Observational Study followed up 93 676 women for an average of 4.1 years .  Depression was measured at baseline with a short form of the Center for Epidemiological Studies Depression Scale .  Risks of cardiovascular disease ( CVD ) events were estimated from Cox proportional hazards models adjusting for multiple demographic , clinical , and risk factor covariates . RESULTS Current depressive symptoms above the screening cutoff point were reported by 15.8 % of women . Depression was significantly related to CVD risk and comorbidity ( odds ratios ranging from 1.12 for hypertension to 1.60 for history of stroke or angina ) . Among women with no history of CVD , depression was an independent predictor of CVD death ( relative risk , 1.50 ) and all-cause mortality ( relative risk , 1.32 ) after adjustment for age , race , education , income , diabetes , hypertension , smoking , high cholesterol level requiring medication , body mass index , and physical activity . Taking antidepressant medications did not alter the depression-associated risks associated . CONCLUSIONS A large proportion of older women report levels of depressive symptoms that are significantly related to increased risk of CVD death and all-cause mortality , even after controlling for established CVD risk factors . Whether early recognition and treatment of sub clinical depression will lower CVD risk remains to be determined in clinical trials Although attention has recently been focused on the role of psychosocial factors in patients with cardiovascular disease ( CVD ) , the factors that have the greatest influence on prognosis have not yet been eluci date d. The aim of this study was to evaluate the effects of depression , anxiety , and anger on the prognosis of patients with CVD . Four hundred fourteen consecutive patients hospitalized with CVD were prospect ively enrolled .  Depression was evaluated using the Patient Health Question naire , anxiety using the Generalized Anxiety Disorder Question naire , and anger using the Spielberger Trait Anger Scale .  Cox proportional-hazards regression was used to examine the individual effects of depression , anxiety , and anger on a combined primary end point of cardiac death or cardiac hospitalization and on a combined secondary end point of all-cause death or hospitalization during follow-up ( median 14.2 months ) . Multivariate analysis showed that depression was a significant risk factor for cardiovascular hospitalization or death after adjusting for cardiac risk factors and other psychosocial factors ( hazard ratio 2.62 , p = 0.02 ) , whereas anxiety was not significantly associated with cardiovascular hospitalization or death after adjustment ( hazard ratio 2.35 , p = 0.10 ) . Anger was associated with a low rate of cardiovascular hospitalization or death ( hazard ratio 0.34 , p < 0.01 ) . In conclusion , depression in hospitalized patients with CVD is a stronger independent risk factor for adverse cardiac events than either anxiety or anger . Anger may help prevent adverse outcomes . Routine screening for depression should therefore be performed in patients with CVD , and the potential effects of anger in clinical practice should be reconsidered AIM To compare three methods of assessing 5-year absolute risk of cardiovascular disease ( CVD ) in adults with type 2 diabetes ; the Framingham CVD equation , the UK Prospect i ve Diabetes Study ( UKPDS ) coronary heart disease plus stroke equations and the New Zeal and Guidelines Group (NZGG)-modified Framingham CVD equation . METHODS Participants were 423 people with newly ( n=118 ) or previously diagnosed ( n=305 ) Type 2 diabetes mellitus aged 35 to 74 years with no past history of cardiovascular disease or nephropathy from an interviewed study population of 4049 adults .  Absolute 5-year CVD risks were calculated in 5-year age b and s by gender ; Maori , Pacific , and European ethnicity ; and newly and previously diagnosed diabetes . RESULTS The mean 5-year CVD risk score was 2.9 % ( 95%CI : 2.40 - 3.42 ; p<0.0001 ) lower for the UKPDS risk engine compared to the original Framingham equation in absolute terms , and 7.6 % ( 95%CI : 7.05 - 8.08 ; p<0.0001 ) lower than the NZGG-modified Framingham equation . In general , 5-year CVD risks were highest using the NZGG-modified equation , intermediate using the original Framingham equation and lowest using the combined UKPDS coronary heart disease plus stroke equations , in all age groups by gender , ethnicity , and time of diagnosis of Type 2 diabetes . However , the 5-year CVD risks are themselves potentially low as they include treated blood pressure and lipid values . Compared to the UKPDS 15 % level of risk , the NZ Guidelines modified 15 % level of risk results in people with diabetes being recommended for CVD drug management 10 to 17 years earlier . CONCLUSIONS In general , among people with Type 2 diabetes , the Framingham equations showed higher 5-year CVD risk estimates compared to combined UKPDS coronary heart disease plus stroke equations and the NZGG-modified Framingham equation showed the highest 5-year CVD risks . In practice , people with type 2 diabetes will be managed earlier and more intensively based on their risk estimated by the current NZGG guidelines than if the UKPDS or original Framingham equations were used 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 Although percentage risk formats are commonly used to convey cardiovascular disease ( CVD ) risk , people find it difficult to underst and these representations . Aims To compare the impact of providing a CVD risk message in either a traditional format ( % risk ) or using an analogy of risk ( Heart-Age ) on participants ' risk perceptions and intention to make lifestyle changes . Methods Four hundred and thirteen men and women were r and omly allocated to one of two conditions ;  CVD risk as a percentage or as a Heart-Age score ( a cardiovascular risk adjusted age ) . Results There was a grade d relationship between perceived and actual CVD risk only in those participants receiving a Heart-Age message ( P<0.05 ) . Heart-Age was more emotionally impactful in younger individuals at higher actual CVD risk ( P<0.01 ) . Self-reported emotional reactions further mediated the relationship between risk perception and intention to make lifestyle changes . Conclusion This study found that the Heart-Age message significantly differed from percentage CVD risk score in risk perceptions and was more emotionally impactful in those participants at higher actual CVD risk levels 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 Background : Evidence on the effectiveness of educational interventions on prescribing behaviour modification in prevention of cardiovascular disease is still insufficient . We evaluated the effects of a brief educational intervention on prescription of hydroxymethylglutaryl-CoA reductase inhibitors ( statins ) , inhibitors of platelet aggregation ( IPA ) , and antihypertensive agents ( AH ) . Design : Cluster r and omised controlled trial with continuous medical education ( CME ) groups of general practitioners ( GPs ) . Methods : Prescription of statins , IPA , and AH were verified prior to study start ( BL ) , immediately after index consultation ( IC ) , and at follow-up after 6 months ( FU ) . Prescription in patients at high risk ( > 15 % risk of a cardiovascular event in 10 years , based on the Framingham equation ) and no prescription in low-risk patients ( ≤ 15 % ) were considered appropriate . Results : An intervention effect on prescribing could only be found for IPA . Generally , changes in prescription over time were all directed towards higher prescription rates and persisted to FU , independent of risk status and group allocation . Conclusions : The active implementation of a brief evidence -based educational intervention on global risk in CVD did not lead directly to risk-adjusted changes in prescription . Investigations on an extended time scale would capture whether decision support of this kind would improve prescribing risk-adjusted sustainably Objective Community-based cardiovascular disease ( CVD ) risk factor screening programs have been used successfully in rural health improvement initiatives . However , little is known about what consumers like or dislike about them , which is a barrier to the design of future process improvements . The objective of this study was to examine the degree to which health risks and participant characteristics predicted screening satisfaction . Design This study utilized a cross-sectional survey design . Setting Data was collected as part of the broader Heart of New Ulm Project , which is a community-based CVD prevention demonstration project based in rural Minnesota . Participants There were 126 r and omly invited individuals from the CVD risk factor screenings , with 118 individuals who agreed to participate and had complete data available for analyses . Methods A multivariate logistic regression analysis was used to examine the association between demographics , lifestyle , and biometric risk factors and screening satisfaction . Results Twenty percent of respondents indicated some level of dissatisfaction with the screening process . Satisfied participants were more likely to be female ( OR=4.15 ) , not have an optimal lifestyle ( OR=3.47 ) , and have an intention to improve their lifestyle habits ( OR=3.26 ) . Age , education , and CVD risk level were not significant predictors in the final model . Conclusion Satisfaction was high in this screening program , with healthy males being least satisfied with their experience . This has implication s for the design of future intervention efforts , as they may require specific programmatic features and more specialized , targeted marketing strategies to attract a broad spectrum of participants likely to benefit Background There is consistent evidence on the impact of health behaviours on risk of cardiovascular disease ( CVD ) in European population s. As South Asians in the UK have an excess risk of CVD and coronary heart disease ( CHD ) compared to Europeans , we investigated whether a similar association between combined health behaviours and risk of CVD and CHD among this high-risk group exists , and estimated the population impact . Methods and Findings In a prospect i ve cohort of 1090 Europeans and 1006 South Asians ( 40–69 y ) without prevalent CVD at baseline ( 1988–1990 ) , followed up for 21 years to 2011 , there were 601 incident CVD events [ Europeans n = 255 ; South Asians n = 346 ] of which 520 were CHD events [ n = 207 and 313 respectively ] . Participants scored between 0 to 4 points for a composite score including four baseline healthy behaviours ( non-smoker , moderate alcohol intake , physically active , frequent fruit/vegetable intake ) . Adjusted hazard ratios ( 95 % confidence intervals ) for incident CHD in Europeans who had three , two , one , and zero compared to four health behaviours were 1.33 ( 0.78–2.29 ) , 1.96 ( 1.15–3.33 ) , 1.36 ( 0.74–2.48 ) and 2.45 ( 1.18–5.10 ) , respectively , p-trend = 0.025 . In South Asians , corresponding HRs were 2.88 ( 1.33–6.24 ) , 2.28 ( 1.06–4.91 ) , 3.36 ( 1.53–7.39 ) and 3.48 ( 1.38–8.81 ) , p-trend = 0.022 . The results were similar for incident CVD ; Europeans HR 2.12 ( 1.14–3.94 ) , p – trend = 0.014 ; South Asians HR 2.73 ( 1.20–6.21 ) , p-trend = 0.018 . The population attributable fraction in Europeans was 43 % for CHD and 28 % for CVD . In South Asians it was 63 % and 51 % respectively . Conclusions Lack of adherence to four combined health behaviours was associated with 2 to 3-fold increased risk of incident CVD in Europeans and South Asians . A substantial population impact in the South Asian group indicates important potential for disease prevention in this high-risk group by adherence to healthy behaviours BACKGROUND Cardiovascular disease ( CVD ) and diabetes account for over one third of the mortality difference between African Americans and white patients . The increased CVD risk in African Americans is due in large part to the clustering of multiple CVD risk factors . OBJECTIVES The current study is aim ed at improving CVD outcomes in African-American adults with diabetes by addressing the modifiable risk factors of systolic blood pressure , glycosylated hemoglobin , and low-density lipoprotein cholesterol . METHODS A sample of African American patients with diabetes ( N = 400 ) will receive written education material at baseline and be r and omized to one of 2 arms : ( 1 ) usual primary care or ( 2 ) nurse-administered disease-management intervention combining patient self-management support and provider medication management . The nurse administered intervention is delivered monthly over the telephone . The nurses also interacts with the primary care providers at 3 , 6 , and 9 months to provide concise patient up date s and facilitate changes in medical management . All patients are followed for 12 months after enrollment . The primary outcomes are change in glycosylated hemoglobin , systolic blood pressure , and low-density lipoprotein cholesterol over 12-months . Secondary outcomes include change in overall cardiovascular risk , aspirin use , and health behaviors . CONCLUSION Given the continued racial disparities in CVD , the proposed study could result in significant contributions to cardiovascular risk reduction in African-American patients Background The global burden of the major vascular diseases is projected to rise and to remain the dominant non-communicable disease cluster well into the twenty first century . The Department of Health in Engl and has developed the NHS Health Check service as a policy initiative to reduce population vascular disease risk . The aims of this study were to monitor population changes in cardiovascular disease ( CVD ) risk factors over the first year of the new service and to assess the value of tailored lifestyle support , including motivational interview with ongoing support and referral to other services . Methods R and omised trial comparing NHS Health Check service only with NHS Health Check service plus additional lifestyle support in Stoke on Trent , Engl and . Thirty eight general practice s and 601 ( 365 usual care , 236 additional lifestyle support ) patients were recruited and r and omised independently between September 2009 and February 2010 . Changes in population CVD risk between baseline and one year follow-up were compared , using intention-to-treat analysis . The primary outcome was the Framingham 10 year CVD risk score . Secondary outcomes included individual modifiable risk measures and prevalence of individual risk categories . Additional lifestyle support included referral to a lifestyle coach and free sessions as needed for : weight management , physical activity , cook and eat and positive thinking . Results Average population CVD risk decreased from 32.9 % to 29.4 % ( p < 0.001 ) in the NHS Health Check only group and from 31.9 % to 29.2 % ( p < 0.001 ) in the NHS Health Check plus additional lifestyle support group . There was no significant difference between the two groups at either measurement point . Prevalence of high blood pressure , high cholesterol and smoking were reduced significantly ( p < 0.01 ) in both groups . Prevalence of central obesity was reduced significantly ( p < 0.01 ) in the group receiving additional lifestyle support but not in the NHS Health Check only group . Conclusions The NHS Health Check service in Stoke on Trent result ed in significant reduction in estimated population CVD risk . There was no evidence of further benefit of the additional lifestyle support services in terms of absolute CVD risk reduction 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 OBJECTIVE To establish a surveillance network for cardiovascular diseases ( CVD ) risk factors in industrial setting s and estimate the risk factor burden using st and ardized tools . METHODS We conducted a baseline cross-sectional survey ( as part of a CVD surveillance programme ) of industrial population s from 10 companies across India , situated in close proximity to medical colleges that served as study centres . The study subjects were employees ( selected by age and sex stratified r and om sampling ) and their family members . Information on behavioural , clinical and biochemical determinants was obtained through st and ardized methods ( question naires , clinical measurements and biochemical analysis ) . Data collation and analyses were done at the national coordinating centre . FINDINGS We report the prevalence of CVD risk factors among individuals aged 20 - 69 years ( n = 19 973 for the question naire survey , n = 10 442 for biochemical investigations ) ; mean age was 40 years . The overall prevalence of most risk factors was high , with 50.9 % of men and 51.9 % of women being overweight , central obesity was observed among 30.9 % of men and 32.8 % of women , and 40.2 % of men and 14.9 % of women reported current tobacco use . Self-reported prevalence of diabetes ( 5.3 % ) and hypertension ( 10.9 % ) was lower than when measured clinical ly and biochemically ( 10.1 % and 27.7 % , respectively ) . There was marked heterogeneity in the prevalence of risk factors among the study centres . CONCLUSION There is a high burden of CVD risk factors among industrial population s across India . The surveillance system can be used as a model for replication in India as well as other developing countries Background — Persons of lower socioeconomic status have greater cardiovascular risk than those of higher socioeconomic status . However , the mechanism through which socioeconomic status affects cardiovascular disease ( CVD ) is uncertain . Virtually no data are available that examine the prospect i ve association between novel inflammatory and hemostatic CVD risk indicators , socioeconomic status , and incident CVD events . Methods and Results — We assessed the relationship between 2 indicators of socioeconomic status ( education and income ) , traditional and novel CVD risk factors ( high sensitivity C-reactive protein , soluble intercellular adhesion molecule-1 , fibrinogen , and homocysteine ) , and incident CVD events among 22 688 apparently healthy female health professionals participating in the Women 's Health Study . These women were followed up for 10 years for the development of myocardial infa rct ion , ischemic stroke , coronary revascularization , and cardiovascular death . More educated women were less likely to be smokers ; had a lower prevalence of hypertension , diabetes , and obesity ; and were more likely to participate in vigorous physical activity than less educated women . At baseline , median total cholesterol , low-density lipoprotein , triglyceride , C-reactive protein , intercellular adhesion molecule-1 , fibrinogen , and homocysteine levels for women in 5 categories of education ( < 2 years of nursing education , 2 to < 4 years of nursing education , a bachelor 's degree , a master 's degree , and a doctoral degree ) and 6 categories of income [ ≤$19 999 , $ 20 000 to $ 29 999 , $ 30 000 to $ 39 999 , $ 40 000 to $ 49 999 , $ 50 000 to $ 99 999 , and ≥$100 000 ) decreased progressively with increasing education or income levels ( all P<0.001 ) , whereas an opposite pattern was observed for high-density lipoprotein ( P<0.001 ) . Overall , in age-adjusted Cox proportional hazards models , the relative risk of incident CVD events decreased with increasing education ( 1.0 , 0.7 , 0.5 , 0.4 , and 0.5 ; P for trend < 0.001 ) and income ( 1.0 , 1.0 , 0.9 , 0.7 , 0.6 , and 0.4 ; P for trend < 0.001 ) categories . In multivariate models that assessed the impact of traditional and novel CVD risk factors on the relationship between education/income and CVD events , the relative hazard of incident CVD associated with a 1-category-higher level of education changed from 0.79 in age- and race-adjusted analysis to 0.89 in fully adjusted analysis . The 11 % lower risk per 1 category of education remained significant ( P for trend=0.006 ) , suggesting that controlling for both novel and traditional risk factors could not explain the protective effect of education . A similar analysis for income revealed that its relationship with CVD events was explained largely by these noted risk factors . Conclusions — In this prospect i ve analysis , we observed a decrease in incident CVD events with increasing levels of education and income . In contrast to the relationship between income and CVD events , the relationship of CVD events with education was explained only partially by traditional and novel risk factors for CVD OBJECTIVES To compare the potential years of life saved ( YOLS ) associated with risk factor modification in the primary and secondary prevention of cardiovascular disease ( CVD ) . METHODS The CVD life expectancy model estimates the risk of death due to coronary disease , stroke , and other causes based on the levels of independent risk factors ( such as age , blood pressure , and blood lipid levels ) found in the cohort of the Lipid Research Clinics . The model was vali date d by comparing its predictions with the observed fatal outcomes of 9 r and omized clinical trials . We then estimated the YOLS associated with treating hyperlipidemia or hypertension among hypothetical patient groups with and without CVD at baseline . We defined high-risk patients as those with 3 risk factors ( hyperlipidemia , cigarette smoking , and hypertension ) and low-risk patients as those with isolated hypertension or hyperlipidemia . RESULTS The fatal events predicted by the model were consistent with the clinical trial results . Among men and women with hyperlipidemia without CVD , the forecasted benefits of lipid therapy  were substantially greater among high-risk groups vs low-risk groups ( 4.74 - 0.78 YOLS vs 2.50 - 0.25 YOLS , respectively ) . Among those with CVD , the forecasted benefits of treatment were similar for both high-risk and low-risk groups ( 4.65 - 0.65 YOLS vs 3.84 - 0.58 YOLS , respectively ) . The results for  hypertension  therapy also demonstrated greater benefits for high-risk vs low-risk patients undergoing primary prevention therapy ( 1.34 - 0.29 YOLS vs 0.85 - 0.13 YOLS , respectively ) , and the forecasted benefits in secondary prevention were similar ( 1.26 - 0.23 YOLS vs 1.00 - 0.23 YOLS , respectively ) . CONCLUSIONS The clinical approach to risk factor modification in primary prevention should be different from that in secondary prevention . The forecasted benefits of therapy among patients without CVD are greatest in the presence of other risk factors . Among those with CVD , the benefits of therapy are equivalent , thereby obviating the need to target high-risk patients ABSTRACT BACKGROUND Many individuals at higher risk for cardiovascular disease ( CVD ) do not receive recommended treatments . Prior interventions using personalized risk information to promote prevention did not test clinic-wide effectiveness . OBJECTIVE AND DESIGN To perform a 9-month cluster-r and omized trial , comparing a strategy of electronic health record-based identification of patients with increased CVD risk and individualized mailed outreach to usual care . PARTICIPANTS Patients of participating physicians with a Framingham Risk Score of at least 5 % , low-density lipoprotein (LDL)-cholesterol level above guideline threshold for drug treatment , and not prescribed a lipid-lowering medication were included in the intention-to-treat analysis .INTERVENTION Patients of physicians r and omized to the intervention group were mailed individualized CVD risk messages that described benefits of using a statin ( and controlling hypertension or quitting smoking when relevant).MAIN MEASURES The primary outcome was occurrence of a LDL-cholesterol level , repeated in routine practice , that was at least 30 mg/dl lower than prior . A secondary outcome was lipid-lowering drug prescribing . Clinical trials.gov identifier : NCT01286311.KEY RESULTS Fourteen physicians with 218 patients were r and omized to intervention , and 15 physicians with 217 patients to control . The mean patient age was 60.7 years and 77 % were male . There was no difference in the primary outcome ( 11.0 % vs. 11.1 % , OR 0.99 , 95 % CI 0.56–1.74 , P = 0.96 ) , but intervention group patients were twice as likely to receive a prescription for lipid-lowering medication ( 11.9 % , vs. 6.0 % , OR 2.13 , 95 % CI 1.05–4.32 , p = 0.038 ) . In post hoc analysis with extended follow-up to 18 months , the primary outcome occurred more often in the intervention group ( 22.5 % vs. 16.1 % , OR 1.59 , 95 % CI 1.05–2.41 , P = 0.029 ) . CONCLUSIONS In this effectiveness trial , individualized mailed CVD risk messages increased the frequency of new lipid-lowering drug prescriptions , but we observed no difference in proportions lowering LDL-cholesterol after 9 months . With longer follow-up , the intervention ’s effect on LDL-cholesterol levels was apparent Objective : To assess nutrient intakes relevant in the prevention of cardiovascular diseases ( CVD ) among young adults in Finl and and to find past and present determinants of quality of diet . Design : Prospect i ve study , 21 years of follow-up . Setting : The Cardiovascular Risk in Young Finns Study , Finl and .Subjects : At baseline in 1980 : 3569 children aged 3–18 y participated ( 83 % of those invited ) , and every second of them ( 1780 ) were selected to the dietary study .  At follow-ups in 1986 and 2001 : 1200 and 1037 of the original sample , respectively , participated . Methods :  Food consumption was assessed using 48-h dietary recall . Intakes in 2001 were compared with those obtained in 1980 and 1986 . Nutrients selected for further examination were those implicated in the risk of CVD : saturated , monounsaturated , polyunsaturated and n-3 fatty acids , fibre and salt . An index describing the quality of adulthood diet was constructed . Multivariate logistic regression was used to identify independent childhood and adulthood determinants of the quality index . Results : The average intakes showed substantial changes since 1980 . Intakes of fat and saturated fat had decreased , while the consumption of vegetables and fruit had increased . However , a great disparity was present between the recommended levels and actual intakes for many of the nutrients , particularly salt , saturated fat and fibre . Intake of fat and consumption of vegetables in childhood and physical activity in adulthood were important health behavioural determinants of the cardiovascular quality of the adult diet . Socio-demographic factors , including education of the subject and their parents , had no significant associations with diet . Conclusions : While intakes of energy and nutrients have changed favourably in Finnish young adults between 1980 and 2001 with regard to the risk of CVD , they are still far from recommended levels . Childhood diet is a significant determinant of adult diet even after 21 y . Sponsorship : This study was supported by the Academy of Finl and ( grant 77841 ) and Juho Vainio Foundation BACKGROUND Studies suggest that moderate drinkers have lower cardiovascular disease ( CVD ) mortality than nondrinkers and heavy drinkers , but there have been no r and omized trials on this topic . Although most observational studies control for major cardiac risk factors , CVD is independently associated with other factors that could explain the CVD benefits ascribed to moderate drinking . METHODS Data from the 2003 Behavioral Risk Factor Surveillance System , a population -based telephone survey of U.S. adults , was used to assess the prevalence of CVD risk factors and potential confounders among  moderate drinkers and nondrinkers . Moderate drinkers were defined as men who drank an average of two drinks per day or fewer , or women who drank one drink or fewer per day . RESULTS After adjusting for age and gender , nondrinkers were more likely to have characteristics associated with increased CVD mortality in terms of demographic factors , social factors , behavioral factors , access to health care , and health-related conditions . Of the 30 CVD-associated factors or groups of factors that we assessed , 27 ( 90 % ) were significantly more prevalent among nondrinkers . Among factors with multiple categories ( e.g. , body weight ) , those in higher-risk groups were progressively more likely to be nondrinkers . Removing those with poor health status or a history of CVD did not affect the results . CONCLUSIONS These findings suggest that some or all of the apparent protective effect of moderate alcohol consumption on CVD may be due to residual or unmeasured confounding . Given their limitations , nonr and omized studies about the health effects of moderate drinking should be interpreted with caution , particularly since excessive alcohol consumption is a leading health hazard in the United States Background We conducted an Internet-based r and omized trial comparing three valence framing presentations of the benefits of antihypertensive medication in preventing cardiovascular disease ( CVD ) for people with newly diagnosed hypertension to determine which framing presentation result ed in choices most consistent with participants ' values . Methods and Findings In this second in a series of televised trials in cooperation with the Norwegian Broadcasting Company , adult volunteers rated the relative importance of the consequences of taking antihypertensive medication using visual analogue scales ( VAS ) . Participants viewed information ( or no information ) to which they were r and omized and decided whether or not to take medication . We compared positive framing over 10 years ( the number escaping CVD per 1000 ) ; negative framing over 10 years ( the number that will have CVD ) and negative framing per year over 10 years of the effects of antihypertensive medication on the 10-year risk for CVD for a 40 year-old man with newly diagnosed hypertension without other risk factors . Finally , all participants were shown all presentations and detailed patient information about hypertension and were asked to decide again . We calculated a relative importance score ( RIS ) by subtracting the VAS-scores for the undesirable consequences of antihypertensive medication from the VAS-score for the benefit of CVD risk reduction . We used logistic regression to determine the association between participants ' RIS and their choice . 1,528 participants completed the study . The statistically significant differences between the groups in the likelihood of choosing to take antihypertensive medication in relation to different values ( RIS ) increased as the RIS increased . Positively framed information lead to decisions most consistent with those made by everyone for the second , more fully informed decision . There was a statistically significant decrease in deciding to take antihypertensives on the second decision , both within groups and overall . Conclusions For decisions about taking antihypertensive medication for people with a relatively low baseline risk of CVD ( 70 per 1000 over 10 years ) , both positive and negative framing result ed in significantly more people deciding to take medication compared to what participants decided after being shown all three of the presentations . Trial Registration International St and ard R and omised Controlled Trial Number Register IS RCT N Background There is currently much interest in encouraging individuals to increase physical activity in order to reduce CVD risk . This study has been design ed to determine if personalised CVD risk appreciation can increase physical activity in adults at high risk of CVD . Methods / Design In a 2 × 2 factorial design participants are allocated at r and om to a personalised 10-year CVD risk estimate or numerical CVD risk factor values ( systolic blood pressure , LDL cholesterol and fasting glucose ) and , simultaneously , to receive a brief lifestyle advice intervention targeting physical activity , diet and smoking cessation or not . We aim to recruit 200 participants from Oxfordshire primary care practice s. Eligibility criteria include adults age 40–70 years , estimated 10-year CVD risk ≥20 % , ability to read and write English , no known CVD and no physical disability or other condition reducing the ability to walk . Primary outcome is physical activity measured by ActiGraph accelerometer with biochemical , anthropometrical and psychological measures as additional outcomes . Primary analysis is between group physical activity differences at one month powered to detect a difference of 30,000 total counts per day of physical activity between the groups . Additional analyses will seek to further eluci date the relationship between the provision of risk information , and intention to change behaviour and to determine the impact of both interventions on clinical and anthropometrical measures including fasting and 2 hour plasma glucose , fructosamine , serum cotinine , plasma vitamin C , body fat percentage and blood pressure . Discussion This is a pilot trial seeking to demonstrate in a real world setting , proof of principal that provision of personalised risk information can contribute to behaviour changes aim ed at reducing CVD risk . This study will increase our underst and ing of the links between the provision of risk information and behaviour change and if successful , could be used in clinical practice with little or no modification BACKGROUND Evidence is limited regarding the impact of healthy lifestyle practice s on the risk of subsequent cardiovascular events among patients with diabetes . OBJECTIVES The purpose of this study was to examine the associations of an overall healthy lifestyle , defined by eating a high- quality diet ( top two-fifths of Alternative Healthy Eating Index ) , nonsmoking , engaging in moderate- to vigorous-intensity physical activity ( ≥150 min/week ) , and drinking alcohol in moderation ( 5 to 15 g/day for women and 5 to 30 g/day for men ) , with the risk of developing cardiovascular disease ( CVD ) and CVD mortality among adults with type 2 diabetes ( T2D ) . METHODS This prospect i ve analysis included 11,527 participants with T2D diagnosed during follow-up ( 8,970 women from the Nurses ' Health Study and 2,557 men from the Health Professionals Follow-Up Study ) , who were free of CVD and cancer at the time of diabetes diagnosis .  Diet and lifestyle factors before and after T2D diagnosis were repeatedly assessed every 2 to 4 years . RESULTS There were 2,311 incident CVD cases and 858 CVD deaths during an average of 13.3 years of follow-up . After multivariate adjustment of covariates , the low-risk lifestyle factors after diabetes diagnosis were each associated with a lower risk of CVD incidence and CVD mortality . The multivariate-adjusted hazard ratios for participants with 3 or more low-risk lifestyle factors compared with 0 were 0.48 ( 95 % confidence interval [ CI ] : 0.40 to 0.59 ) for total CVD incidence , 0.53 ( 95 % CI : 0.42 to 0.66 ) for incidence of coronary heart disease , 0.33 ( 95 % CI : 0.21 to 0.51 ) for stroke incidence , and 0.32 ( 95 % CI : 0.22 to 0.47 ) for CVD mortality ( all p trend < 0.001 ) . The population -attributable risk for poor adherence to the overall healthy lifestyle ( <3 low-risk factors ) was 40.9 % ( 95 % CI : 28.5 % to 52.0 % ) for CVD mortality . In addition , greater improvements in healthy lifestyle factors from pre-diabetes to post-diabetes diagnosis were also significantly associated with a lower risk of CVD incidence and CVD mortality . For each number increment in low-risk lifestyle factors there was a 14 % lower risk of incident total CVD , a 12 % lower risk of coronary heart disease , a 21 % lower risk of stroke , and a 27 % lower risk of CVD mortality ( all p < 0.001 ) . Similar results were observed when analyses were stratified by diabetes duration , sex/cohort , body mass index at diabetes diagnosis , smoking status , and lifestyle factors before diabetes diagnosis . CONCLUSIONS Greater adherence to an overall healthy lifestyle is associated with a substantially lower risk of CVD incidence and CVD mortality  among adults with T2D . These findings further support the tremendous benefits of adopting a healthy lifestyle in reducing the subsequent burden of cardiovascular complications in patients with T2D Although diet quality is implicated in cardiovascular disease ( CVD ) risk , few studies have investigated the relation between diet quality and the risks of  CVD and mortality in older adults . This study examined the prospect i ve associations between dietary scores and risk of CVD and all-cause mortality in older British men . A total of 3328 men ( aged 60–79 y ) from the British Regional Heart Study , free from CVD at baseline , were followed up for 11.3 y for CVD and mortality . Baseline food-frequency question naire data were used to generate 2 dietary scores :  the Healthy Diet Indicator ( HDI ) , based on WHO dietary guidelines , and the Elderly Dietary Index ( EDI ) , based on a Mediterranean-style dietary intake , with higher scores indicating greater compliance with dietary recommendations . Cox proportional hazards regression analyses assessed associations between quartiles of HDI and EDI and risk of all-cause mortality , CVD mortality , CVD events , and coronary heart disease ( CHD ) events . During follow-up , 933 deaths , 327 CVD deaths , 582 CVD events , and 307 CHD events occurred . Men in the highest compared with the lowest EDI quartile had significantly lower risks of all-cause mortality ( HR : 0.75 ; 95 % CI : 0.60 , 0.94 ; P-trend = 0.03 ) , CVD mortality ( HR : 0.63 ; 95 % CI : 0.42 , 0.94 ; P-trend = 0.03 ) , and CHD events ( HR : 0.66 ; 95 % CI : 0.45 , 0.97 ; P-trend = 0.05 ) but not CVD events ( HR : 0.79 ; 95 % CI : 0.60 , 1.05 ; P-trend = 0.16 ) after adjustment for sociodemographic , behavioral , and cardiovascular risk factors . The HDI was not significantly associated with any of the outcomes . The EDI appears to be more useful than the HDI for assessing diet quality in relation to CVD and morality risk  in older men . Encouraging older adults to adhere to the guidelines inherent in the EDI criteria may have public health benefits 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 In 1998 , the American Heart Association convened Prevention Conference V to examine strategies for the identification of high-risk patients who need primary prevention . Among the strategies discussed was the measurement of markers of inflammation.1  The Conference concluded that “ many of these markers ( including inflammatory markers ) are not yet considered applicable for routine risk assessment because of : ( 1 ) lack of measurement st and ardization , ( 2 ) lack of consistency in epidemiological findings from prospect i ve studies with endpoints , and ( 3 ) lack of evidence that the novel marker adds to risk prediction over and above that already achievable through the use of established risk factors . ” The National Cholesterol Education Program Adult Treatment Panel III Guidelines identified these markers as emerging risk factors,1a which could be used as an optional risk factor measurement to adjust estimates of absolute risk obtained using st and ard risk factors . Since these publications , a large number of peer- review ed scientific reports have been published relating inflammatory markers to cardiovascular disease ( CVD ) . Several commercial assays for inflammatory markers have become available . As a consequence of the exp and ing research base and availability of assays , the number of inflammatory marker tests ordered by clinicians for CVD risk prediction has grown rapidly . Despite this , there has been no consensus from professional societies or governmental agencies as to how these assays of markers of inflammation should be used in clinical practice . On March 14 and 15 , 2002 , a workshop titled “ CDC/AHA Workshop on Inflammatory Markers and Cardiovascular Disease : Applications to Clinical and Public Health Practice ” was convened in Atlanta , Ga , to address these issues . The goals of this workshop were to determine which of the currently available tests should be used ; what results should be used to define high risk ; which patients should be tested ; and the indications for which the tests would be most useful . These Objectives A policy model is a model that can evaluate the effectiveness and cost-effectiveness of interventions and inform policy decisions . In this study , we introduce a cardiovascular disease ( CVD ) policy model which can be used to model remaining life expectancy including a measure of socioeconomic deprivation as an independent risk factor for CVD . Design A state transition model was developed using the Scottish Heart Health Extended Cohort ( SHHEC ) linked to Scottish morbidity and death records . Individuals start in a CVD-free state and can transit to three CVD event states plus a non-CVD death state . Individuals who have a non-fatal first event are then followed up until death . Taking a competing risk approach , the cause-specific hazards of a first event are modelled using parametric survival analysis . Survival following a first non-fatal event is also modelled parametrically . We assessed discrimination , validation and calibration of our model . Results Our model achieved a good level of discrimination in each component ( c-statistics for men (women)—non-fatal coronary heart disease ( CHD ) : 0.70 ( 0.74 ) , non-fatal cerebrovascular disease ( CBVD ) : 0.73 ( 0.76 ) , fatal CVD : 0.77 ( 0.80 ) , fatal non-CVD : 0.74 ( 0.72 ) , survival after non-fatal CHD : 0.68 ( 0.67 ) and survival after non-fatal CBVD : 0.65 ( 0.66 ) ) . In general , our model predictions were comparable with observed event rates for a Scottish r and omised statin trial population which has an overlapping follow-up period with SHHEC . After applying a calibration factor , our predictions of life expectancy closely match those published in recent national life tables . Conclusions Our model can be used to estimate the impact of primary prevention interventions on life expectancy and can assess the impact of interventions on inequalities OBJECTIVES This study was design ed to examine the hypothesis that higher intake of dietary fiber is inversely related to the  risk of cardiovascular disease ( CVD ) and myocardial infa rct ion ( MI ) in a large prospect i ve cohort of women . BACKGROUND Although dietary fiber has been suggested to reduce the risk of coronary disease , few prospect i ve studies have examined the association between the types and amounts of dietary fiber and CVD risk , particularly among women . METHODS In 1993 , we used a semi-quantitative food frequency question naire to assess dietary fiber intake among 39,876 female health professionals with no previous history of CVD or cancer . Women were subsequently followed for an average of six years for incidence of nonfatal MI , stroke , percutaneous transluminal coronary angioplasty , coronary artery bypass graft or death due to CVD confirmed by medical records or death certificates . RESULTS During 230,006 person-years of follow-up , 570 incident cases of CVD were documented , including 177 MIs . After adjustment for age and r and omized treatment status , a significant inverse association was observed between dietary fiber intake and CVD risk . Comparing the highest quintile of fiber intake ( median : 26.3 g/day ) with the lowest quintile ( median : 12.5 g/day ) , the relative risks ( RR ) were 0.65 ( 95 % confidence interval [ CI ] : 0.51 , 0.84 ) for total CVD and 0.46 ( 95 % CI : 0.30 , 0.72 ) for MI . Additional adjustment for CVD risk factors reduced the RRs to 0.79 ( 95 % CI : 0.58 , 1.09 ) for total CVD and 0.68 ( 95 % CI : 0.36 , 1.22 ) for MI . The inverse trends across categories generally remained , although they were no longer statistically significant . Inverse relations were observed between both soluble and insoluble fiber and risk of CVD and MI , and among those who had never smoked and those with body mass index < 25 . CONCLUSIONS A higher intake of  dietary fiber was associated with a lower risk of CVD and MI , although the association was not statistically significant after further adjusting for multiple confounding factors . Nevertheless , these prospect i ve data generally support current dietary recommendations to increase the consumption of fiber-rich whole grains and fruits and vegetables as a primary preventive measure against CVD We used outcome data from a r and omized work site intervention trial to examine the cost-effectiveness of four cardiovascular disease ( CVD ) risk reduction programs : health risk assessment ( HRA ) , risk factor education ( RFE ) , behavioral counseling ( BC ) , and behavioral counseling plus incentives ( BCI ) . Composite CVD risk scores were derived from measures of serum total cholesterol , blood pressure , number of cigarettes smoked , body mass index , and aerobic capacity . The economic evaluation of the programs focused on the subset of costs most sensitive to the differences between the interventions , and a sensitivity analysis examined some of the relevant cost variations . At the 6-month follow-up ( i.e. , the " action " or initiation stage of lifestyle change ) , the RFE , BC , and BCI interventions produced a significant reduction in cardiovascular risk . Incremental analyses demonstrated RFE to be more cost-effective , but not as clinical ly effective as BC ; BC was more cost-effective than RFE when assessment costs were included , and BCI was judged to be the least cost-effective . At the 12-month follow-up ( i.e. , the " maintenance " stage of lifestyle of change ) , BC was the only program found to produce a significant reduction in CVD risk .  Individualized behavioral counseling was found to be a cost-effective strategy for the initiation and maintenance of CVD risk factor reduction BACKGROUND Determination of  C-reactive protein ( CRP ) level has been suggested to improve cardiovascular disease ( CVD ) risk assessment . This study examines the utility of CRP levels to assess CVD risk in a community setting . METHODS We performed a prospect i ve observational cohort study on a community population sample . A total of 1949 men and 2497 women without CVD from the Framingham Heart Study underwent CVD risk factor assessment . Initial CVD events during 8 years of follow-up were recorded . RESULTS There were 283 major CVD and 160 major coronary heart disease incident events . Age- , sex- , and multivariable-adjusted analyses generally used CRP level categories of less than 1 , 1 to 3 , and greater than 3 mg/L. In age- and sex-adjusted models , the traditional risk factors and elevated CRP levels indicated increased risk . The age- and sex-adjusted relative risk ( RR ) and 95 % confidence interval ( CI ) of CRP level greater than 3 mg/L for major CVD was elevated ( RR , 1.60 ; 95 % CI , 1.19 - 2.14 ) , with evidence of attenuation ( RR , 1.22 ; 95 % CI , 0.90 - 1.66 ) in multivariable models . The C statistic , a measure of the discriminatory capability of the prediction models , was 0.74 for prediction of major CVD with age and CRP level . In multivariable models that included traditional risk factors , the C statistic was 0.78 , a value that was unchanged with the addition of CRP to the multivariable model . Similar relations were noted for major coronary heart disease events . CONCLUSION Elevated CRP level provided no further prognostic information beyond traditional office risk factor assessment to predict future major CVD and major coronary heart disease in this population sample Abstract BACKGROUND : Quality of cardiovascular disease ( CVD ) preventive care is suboptimal . Recent data correlated increasing years in practice for physicians with lower- quality health care . OBJECTIVE : The purpose of this study was to assess physician awareness/adherence to national blood pressure , cholesterol , and CVD prevention guidelines for women according to physician/ practice characteristics . DESIGN : St and ardized online survey and experimental case studies were administered to 500 r and omly selected U.S. physicians . Multivariable regression models tested physician age , gender , specialty , and practice type as independent predictors of guideline awareness/adherence . RESULTS : Compared with older physicians ( 50 + years ) , younger physicians ( < 50 years ) reported a lower level of awareness of cholesterol guidelines ( P=.04 ) and lower incorporation of women ’s guidelines ( P=.02 ) . Yet , older physicians were less likely to recommend weight management for high-risk cases ( P=.03 ) and less confident in helping patients manage weight ( P=.045 ) than younger physicians . Older physicians were also less likely to identify a low-density lipoprotein < 100 mg/dL as optimal versus younger physicians ( P=.01 ) , as were solo versus nonsolo practitioners ( P=.02 ) . Solo practitioners were less aware of cholesterol guidelines ( P=.04 ) and were more likely to prescribe aspirin  for low-risk female patients than nonsolo practitioners ( P<.01 ) . Solo practitioners rated their clinical judgment as more effective than guidelines in improving patient health outcomes ( P<.01 ) and more frequently rated the patient as the greatest barrier to CVD prevention versus nonsolo practitioners ( P<.01 ) . CONCLUSIONS : Though guideline awareness is high , efforts to promote their utilization are needed and may improve quality outcomes . Targeted education and support for CVD prevention may be helpful to older and solo physicians Background — Framingham-based and Reynolds Risk scores for cardiovascular disease ( CVD ) prediction have not been directly compared in an independent validation cohort . Methods and Results — We selected a case-cohort sample of the multiethnic Women 's Health Initiative Observational Cohort , comprising 1722 cases of major CVD ( 752 myocardial infa rct ions , 754 ischemic strokes , and 216 other CVD deaths ) and a r and om subcohort of 1994 women without prior CVD . We estimated risk using the  Adult Treatment Panel III ( ATP-III ) score , the Reynolds Risk Score , and the Framingham CVD model , reweighting to reflect cohort frequencies . Predicted 10-year risk varied widely between models , with ≥10 % risk in 6 % , 10 % , and 41 % of women with the ATP-III , Reynolds , and Framingham CVD models , respectively . Calibration was adequate for the Reynolds model , but the ATP-III and Framingham CVD models overestimated risk for coronary heart disease and major CVD , respectively . After recalibration , the Reynolds model demonstrated improved discrimination over the ATP-III model through a higher c statistic ( 0.765 versus 0.757 ; P=0.03 ) , positive net reclassification improvement ( NRI ; 4.9 % ; P=0.02 ) , and positive integrated discrimination improvement ( 4.1 % ; P<0.0001 ) overall , excluding diabetics ( NRI=4.2 % ; P=0.01 ) , and in white ( NRI=4.3 % ; P=0.04 ) and black ( NRI=11.4 % ; P=0.13 ) women . The Reynolds ( NRI=12.9 % ; P<0.0001 ) and ATP-III ( NRI=5.9 % ; P=0.0001 ) models demonstrated better discrimination than the Framingham CVD model . Conclusions — The Reynolds Risk Score was better calibrated than the Framingham-based models in this large external validation cohort . The Reynolds score also showed improved discrimination overall and in black and white women . Large differences in risk estimates exist between models , with clinical implication s for statin therapy BACKGROUND Emerging evidence suggests a possible role of lycopene in the primary prevention of cardiovascular disease ( CVD ) . OBJECTIVE We examined whether plasma lycopene concentrations in the Physicians ' Health Study were associated with CVD in a prospect i ve , nested , case-control design . DESIGN Baseline blood sample s were collected starting in 1996 . During a mean follow-up of 2.1 y , we identified 499 cases of CVD ( confirmed myocardial infa rct ion , stroke , CVD death , or revascularization procedures ) and an equal number of men free of CVD and matched for age ( x : 69.7 y ) , follow-up time , and smoking status . We collected self-reported coronary disease risk factors and measured plasma carotenoids , retinol , lipids , and C-reactive protein . RESULTS In matched analyses with additional adjustment for plasma total cholesterol and r and omized treatment , the relative risks ( RRs ) of CVD for men in the lowest to highest quartiles of plasma lycopene were 1.00 ( reference ) , 0.92 , 1.04 , and 0.95 ( P for linear trend = 0.93 ) . With multivariate adjustment , the RRs of total CVD were 1.00 ( reference ) , 1.08 , 0.94 , and 1.03 ( P for linear trend = 0.98 ) . For important vascular events ( 241 cases ) , excluding revascularization procedures , the multivariate RRs remained nonsignificant ( P for linear trend = 0.50 ) . Adding plasma carotenoids , lipids , or C-reactive protein to multivariate models had a minimal effect on the RRs of total CVD for plasma lycopene . Compared with lycopene , higher concentrations of plasma lutein/zeaxanthin and retinol suggested a moderate increase in CVD risk , whereas no association was found for beta-cryptoxanthin , alpha-carotene , and beta-carotene . CONCLUSIONS Higher plasma lycopene concentrations were not associated with the risk of CVD in this study of older men . Further evaluation in diverse population s is necessary 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 Patients with type 2 diabetes mellitus ( T2DM ) have an increased risk to develop severe diabetes related complications , especially cardiovascular disease ( CVD ) . The risk to develop CVD can be estimated by means of risk formulas . However , patients have difficulties to underst and the outcomes of these formulas . As a result , they may not recognize the importance of changing lifestyle and taking medication in time . Therefore , it is important to develop risk communication methods , that will improve the patients ' underst and ing of risks associated with having diabetes , which enables them to make informed choices about their diabetes care . The aim of this study is to investigate the effects of an intervention focussed on the communication of the absolute 10-year risk to develop CVD on risk perception , attitude and intention to change lifestyle behaviour in patients with T2DM . The conceptual framework of the intervention is based on the Theory of Planned Behaviour and the Self-regulation Theory . Methods A r and omised controlled trial will be performed in the Diabetes Care System West-Friesl and ( DCS ) , a managed care system . Newly referred T2DM patients of the DCS , younger than 75 years will be eligible for the study . The intervention group will be exposed to risk communication on CVD , on top of st and ard managed care of the DCS . This intervention consists of a simple explanation on the causes and consequences of CVD , and possibilities for prevention . The probabilities of CVD in 10 year will be explained in natural frequencies and visualised by a population diagram . The control group will receive st and ard managed care . The primary outcome is appropriateness of risk perception . Secondary outcomes are attitude and intention to change lifestyle behaviour and illness perception . Differences between baseline and follow-up ( 2 and 12 weeks ) between groups will be analysed according to the intention-to-treat principle . The study was powered on 120 patients in each group . Discussion This innovative risk communication method based on two behavioural theories might improve patient 's appropriateness of risk perception and attitude concerning lifestyle change . With a better underst and ing of their CVD risk , patients will be able to make informed choices concerning diabetes care . Trail registration The trial is registered as NTR1556 in the Dutch Trial Register OBJECTIVE To determine how change in BMI over 8 years is associated with risk of subsequent cardiovascular disease ( CVD ) among middle aged men . METHODS Prospect i ve cohort study among 13,230 healthy men ( aged 51.6+/-8.7 years ) in the Physicians ' Health Study .  BMI was collected at baseline in 1982 and after 8 years , at which time follow-up began . Subsequent CVD events were collected and confirmed through March 31 , 2005 . Cox proportional hazards models evaluated  BMI  at 8 years and risk of CVD , 8-year change in BMI and risk of CVD , and whether change in BMI added prognostic information after the consideration of BMI at 8 years . RESULTS 1308 major CVD events occurred over 13.5 years . A higher BMI at year 8 was associated with an increased risk of CVD . Compared to a stable BMI ( + /-0.5 kg/m(2 ) ) , a 0.5 - 2.0 kg/m(2 ) increase had a multivariable-adjusted RR of 1.00 ( 0.86 - 1.16 ) . A > /=2.0 kg/m(2 ) increase had a multivariable-adjusted RR of 1.39 ( 1.16 - 1.68 ) , however further adjustment for BMI reduced the RR to 1.00 ( 0.81 - 1.23 ) . A decrease in BMI had a multivariable RR of 1.23 ( 1.07 - 1.42 ) which was unaffected by adjustment for BMI at 8 years . CONCLUSION A higher BMI and a rising BMI were both associated with an increased risk of CVD , however an increasing BMI did not add prognostic information once current BMI was considered . In contrast , a declining BMI was associated with an increased risk of CVD independent of current BMI 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 Context : The benefit of weight reduction for cardiovascular disease ( CVD ) outcomes remains uncertain . Objective : To examine the effects of baseline body mass index on major CVD outcomes and diabetes over a 20 year follow up , and of weight change in the first five years over the subsequent 15 years . Design and setting : A prospect i ve study of British men followed up for 20 years . Participants : Men aged 40–59 years with no diagnosis of CVD or diabetes ( n = 7176 ) of whom 6798 provided full information on weight change five years later . Outcome measures : Major CVD events ( fatal and non-fatal myocardial infa rct ion and stroke , angina , “ other ” CVD deaths ) and diabetes . Results : During the 20 year follow up there were 1989 major CVD events and 449 incident cases of diabetes in the 7176 men . Risk of major CVD and diabetes increased significantly with increasing overweight and obesity . During the 15 year follow up , weight gain was associated with increased risk of CVD and diabetes . Weight loss was associated with lower risk of diabetes than the stable group irrespective of initial weight . No significant cardiovascular benefit was seen for weight loss in any men , except possibly in considerably overweight ( BMI 27.5–29.9 kg/m2 ) younger middle aged men ( RR = 0.42 ; 95 % CI 0.22 to 0.81 ) . Conclusion : Long term risk of CVD and diabetes increased significantly with increasing overweight and obesity . Weight loss was associated with significant reduction in risk of diabetes but not CVD , except possibly in considerably overweight younger men . Duration and severity of obesity seem to limit the cardiovascular benefits of weight reduction in older men BACKGROUND The  Dietary Inflammatory Index ( DII ) is a comprehensive , literature -derived index for assessing the effect of dietary constituents on inflammatory biomarkers . Several studies have shown an association between DII score and mortality , but there are limited prospect i ve studies in Asian population s. OBJECTIVES The aim of this study was to investigate the association between DII score and risk of all-cause , total cardiovascular disease ( CVD ) , stroke , coronary heart disease ( CHD ) , total cancer , digestive cancer , and noncancer/non-CVD mortality in the Japanese population . METHODS A total of 58,782 Japanese participants aged 40 - 79 y who were enrolled in the Japan Collaborative Cohort Study during 1988 - 1990 were included in the analysis .  DII scores were calculated based on a food-frequency question naire . HRs and 95 % CIs for mortality according to DII quintiles were estimated using Cox proportional hazards models . RESULTS During the median follow-up period of 19.3 y , a total of 11,693 participants died . The multivariable HR for all-cause mortality for the highest compared with the lowest DII quintiles was 1.13 ( 95 % CI : 1.05 , 1.21 ) . For CVD mortality , the highest multivariable HRs were 1.30 ( 95 % CI : 1.13 , 1.49 ) , 1.29 ( 95 % CI : 1.05 , 1.59 ) , and 1.30 ( 95 % CI : 0.96 , 1.76 ) for total CVD , stroke , and CHD , respectively . No significant associations were observed between DII and risk of total cancer , digestive cancer , and noncancer/non-CVD mortality . CONCLUSION Our findings suggest that a higher DII was associated with an increased risk of all-cause and CVD mortality among Japanese adults Background Intensive diet and physical activity interventions have been found to reduce cardiovascular disease ( CVD ) risk , but are re source intensive . The American Heart Association recently recommended motivational interviewing ( MI ) as an effective approach for low-intensity interventions to promote health-related outcomes such as weight loss . However , there is limited research evaluating the long-term effectiveness of MI-based interventions on health-related outcomes associated with CVD risk . The current research evaluated the effectiveness of a six-month low-intensity MI intervention in a UK primary -care setting in maintaining reductions in CVD risk factors at12 months post-intervention . Methods Primary -care patients were r and omised to an intervention group that received st and ard exercise and nutrition information plus up to five face-to-face MI sessions , delivered by a physical activity specialist and registered dietician over a 6-month period , or to a minimal intervention comparison group that received the st and ard information only . Follow-up measures of behavioural ( vigorous and moderate physical activity , walking , physical activity stage-of-change , fruit and vegetable intake , and dietary fat intake ) and biomedical ( weight , body mass index [ BMI ] , blood pressure , cholesterol ) outcomes were taken immediately post-intervention and at a 12-month follow-up occasion . Results Intent-to-treat analyses revealed significant differences between groups for walking and cholesterol .  Obese and hypercholesterolemic patients at baseline exhibited significant improvements in BMI and cholesterol respectively among those allocated to the intervention group compared to the comparison group . Post-intervention improvements in other health-related outcomes including blood pressure , weight , and BMI were not maintained . Conclusions The present study suggests that a low-intensity MI counselling intervention is effective in bringing about long-term changes in some , but not all , health-related outcomes ( walking , cholesterol levels ) associated with CVD risk . The intervention was particularly effective for patients with elevated levels of CVD risk factors at baseline . Based on these findings future interventions should be conducted in a primary care setting and target patients with high risk of CVD . Future research should investigate how the long-term gains in health-related outcomes brought about by the MI-counselling intervention in the current study could be extended to a wider range of health outcomes BACKGROUND High homocysteine concentrations may be neurotoxic and contribute to cognitive decline in older persons . OBJECTIVE The objective was to examine the effect of supplementation with folic acid , vitamin B-12 , and vitamin B-6 on cognitive change in women with cardiovascular disease ( CVD ) or CVD risk factors . DESIGN The Women 's Antioxidant and Folic Acid Cardiovascular Study is a r and omized placebo-controlled trial design ed to test the effect of a combination of B vitamins ( 2.5 mg folic acid/d , 50 mg vitamin B-6/d , and 1 mg vitamin B-12/d ) on secondary prevention of CVD . Female health professionals aged > or=40 y ( n = 5442 ) with CVD or > or=3 coronary risk factors in 1998 ( after folic acid fortification began in the United States ) were r and omly assigned to treatment . Shortly after r and omization ( mean : 1.2 y ) , a sub study of cognitive function was initiated among 2009 participants aged > or=65 y.  Telephone cognitive function testing was administered up to 4 times over 5.4 y with 5 tests of general cognition , verbal memory , and category fluency . Repeated- measures analyses were conducted , and the primary outcome was a global composite score averaging all test results . RESULTS Mean cognitive change from baseline did not differ between the B vitamin and placebo groups ( difference in change in global score : 0.03 ; 95 % CI : -0.03 , 0.08 ; P = 0.30 ) . However , supplementation appeared to preserve cognition among women with a low baseline dietary intake of B vitamins . CONCLUSIONS Combined B vitamin supplementation did not delay cognitive decline  among women with CVD or CVD risk factors . The possible cognitive benefits of supplementation among women with a low dietary intake of B vitamins warrant further study BACKGROUND Psychosocial factors are independently associated with increased risk of cardiovascular disease ( CVD ) morbidity and mortality , but the effects of psychosocial factor intervention on CVD are uncertain . We performed a r and omized controlled clinical trial of cognitive behavioral therapy ( CBT ) to measure its effects on CVD recurrence . METHODS The study included 362 women and men 75 years or younger who were discharged from the hospital after a coronary heart disease event within the past 12 months . Patients were r and omized to receive traditional care  ( reference group , 170 patients ) or traditional care plus a CBT program ( intervention group , 192 patients ) , focused on stress management , with 20 two-hour sessions during 1 year . Median attendance at each CBT session was 85 % . Outcome variables were all-cause mortality , hospital admission for recurrent CVD , and recurrent acute myocardial infa rct ion . RESULTS During a mean 94 months of follow-up , the intervention group had a 41 % lower rate of fatal and nonfatal first recurrent CVD events ( hazard ratio [ 95 % confidence interval ] , 0.59 [ 0.42 - 0.83 ] ; P = .002 ) , 45 % fewer recurrent acute myocardial infa rct ions ( 0.55 [ 0.36 - 0.85 ] ; P = .007 ) , and a nonsignificant 28 % lower all-cause mortality ( 0.72 [ 0.40 - 1.30 ] ; P = .28 ) than the reference group after adjustment for other outcome -affecting variables . In the CBT group there was a strong dose-response effect between intervention group attendance and outcome . During the first 2 years of follow-up , there were no significant group differences in traditional risk factors . CONCLUSIONS A CBT intervention program decreases the risk of recurrent CVD and recurrent acute myocardial infa rct ion . This may have implication s for secondary preventive programs in patients with coronary heart disease . Trial Registration clinical trials.gov Identifier : NCT00888485 Background The increasing burden of cardiovascular diseases ( CVD ) in the ageing population of industrialized nations requires an intensive search for means of reducing this epidemic . In order to improve prevention , detection , therapy and prognosis of cardiovascular diseases on the population level in Eastern Germany , it is necessary to examine reasons for the East-West gradient of CVD morbidity and mortality , potential causal mechanisms and prognostic factors in the elderly . Psychosocial and nutritional factors have previously been discussed as possible causes for the unexplained part of the East-West gradient . A reduced heart rate variability appears to be associated with cardiovascular disease as well as with psychosocial and other cardiovascular risk factors and decreases with age . Nevertheless , there is a lack of population -based data to examine the role of heart rate variability and its interaction with psychosocial and nutritional factors regarding the effect on cardiovascular disease in the ageing population . There also is a paucity of epidemiological data describing the health situation in Eastern Germany . Therefore , we conduct a population -based study to examine the distribution of CVD , heart rate variability and CVD risk factors and their associations in an elderly East German population . This paper describes the design and objectives of the CARLA Study . Methods / design For this study , a r and om sample of 45–80 year-old inhabitants of the city of Halle ( Saale ) in Eastern Germany was drawn from the population registry . By the end of the baseline examination ( 2002–2005 ) , 1750 study participants will have been examined . A multi-step recruitment strategy aims at achieving a 70 % response rate . Detailed information is collected on own and family medical history , socioeconomic , psychosocial , behavioural and biomedical factors . Medical examinations include  anthropometric measures , blood pressure of arm and ankle , a 10-second and a 20-minute electrocardiogram , a general physical examination , an echocardiogram , and laboratory analyses of venous blood sample s.  On 200 participants , a 24-hour electrocardiogram  is recorded . A detailed system of quality control ensures high data quality . A follow-up examination is planned . Discussion This study will help to eluci date pathways to CVD involving autonomic dysfunction and lifestyle factors which might be responsible for the CVD epidemic in some population Aims To test whether communicating cardiovascular diseases ( CVD ) risk using a novel risk assessment tool ( Heart Age ) will be able to motivate a population to adopt healthier lifestyles and improve CVD risk profile over the use of a traditional percentage-based tool . Methods A single-blind r and omized intervention study was carried out in a Caucasian population . A total of 3153 subjects were r and omly allocated to one of three study groups : control ( conventional medical advice was given to the subjects ) , Framingham REGICOR ( 10-year percentage risk score , calibrated to Spanish population was given to the subjects ) , or Heart Age group ( Heart Age tool was administered to the subjects ) . Anthropometrical and metabolic parameters were measured and lifestyle habits were recorded at recruitment and 12-months post intervention . Results Both the Framingham REGICOR and the Heart Age intervention groups demonstrated significant decreases in their risk scores at post intervention compared to the control group , with the improvement being of a greater magnitude in the Heart Age group . No differences per gender were observed in the Heart Age group . Conclusions Informing patients about their CVD risk expressed as the new Heart Age tool results in a reduction in their CVD risk higher than the one observed when the Framingham REGICOR risk score was used Abstract The study aim ed to investigate whether meeting leisure time physical activity recommendations was associated with reduced incident and fatal cancer or cardiovascular disease ( CVD )  in a community-based cohort of middle- to late-aged adults with long-term follow-up . At baseline , 2,320 individuals were assessed on a large number of lifestyle and clinical parameters including their level of physical activity  per week , other risk factors ( e.g. smoking and alcohol use ) various anthropometric measures , blood tests and medical history . Individuals were linked to hospital and mortality registry data to identify future cancer and cardiovascular events ( fatal and non-fatal ) out to 15 years of follow-up . Cox regression analyses adjusted for relevant confounders identified a priori were used to estimate risk for all-cause , cancer-specific and CVD-specific mortality . In the full cohort an estimated 21 % decreased risk for all-cause mortality ( HR 0.79 ; 95 % CI 0.66–0.96 ) and 22 % decreased risk for fatal/non-fatal CVD events ( HR 0.78 ; 95 % CI 0.66–0.92 ) was associated with baseline self-reported physical activity levels of 150 min or more . After exclusion of those with chronic co-morbidities ( CVD , cancer , diabetes , chronic obstructive pulmonary disease , hypertension treatment ) at baseline , lower risk for fatal/non-fatal CVD events remained significantly associated with 150 min or more of physical activity ( HR 0.77 ; 95 % CI 0.62–0.96 ) . Results from this well established prospect i ve community-based cohort study support the role of leisure time physical activity in reducing all-cause mortality and CVD events ( fatal/nonfatal ) in the broader population studied . The data also suggest that physical activity associated reductions in risk for CVD events ( fatal/nonfatal ) were not overly impacted by prevalent key non-communicable diseases Background There is nonoptimal adherence of general practitioners ( GPs ) and patients to cardiovascular risk reducing interventions . GPs find it difficult to assimilate multiple risk factors into an accurate assessment of cardiovascular risk . In addition , communicating cardiovascular risk to patients has proved to be difficult . Aims Improving primary prevention of cardiovascular disease ( CVD ) in primary care by enhancing patient involvement in the use of a decision support tool . Design Cluster r and omized trial . Methods Thirty-four GPs included patients ( 40 - 75 years old ) without CVD . In an interactive , small group training session lasting 4h , the GPs in the intervention group were trained to use the guidelines on cardiovascular risk and a decision support tool . The control group received educational material s about the guidelines on paper .  GPs ’ clinical performance and patients ’ risk perception and self-reported lifestyles were measured at baseline and after 6 months . Results Thirty-four GPs recorded 490 consultations , 276 in the intervention and 214 in the control group . After 6 months , no significant effect of the intervention on the GPs ’ performance or the patients ’ risk perception was found . There was only an effect on self-reported lifestyle , in that more men in the intervention group than in the control group increased their physical activity ( odds ratio 3.8 , 95 % confidence interval 1.7–8.7 ) . Conclusion The 4-h interactive , small group training did not guarantee correct application of the decision support tool and as such failed to improve GPs ’ performance or correct patients ’ risk perception . The positive effect on physical activity justifies further research on patient involvement . Eur J Cardiovasc Prev Rehabil 14 : 44 - 50 © 2007 The European Society of OBJECTIVE The Diabetes Prevention Program demonstrated the ability to delay or prevent type 2 diabetes in participants with impaired glucose tolerance ( IGT ) . Participants with IGT are at high risk for cardiovascular disease ( CVD ) , with a marked increase in the number and severity of CVD risk factors . We prospect ively assessed the impact of our interventions on hypertension , dyslipidemia , and CVD events . RESEARCH DESIGN AND METHODS The study group consisted of 3,234 individuals with IGT r and omly assigned to receive intensive lifestyle intervention , metformin , or placebo . Annual assessment of blood pressure , lipids , electrocardiogram , and CVD events was undertaken . RESULTS Hypertension was present in 30 % of participants at study entry and then increased in the placebo and metformin groups , although it significantly decreased with intensive lifestyle intervention . Triglyceride levels fell in all treatment groups , but fell significantly more with intensive lifestyle intervention . Total cholesterol and LDL cholesterol levels were similar among treatment groups . Intensive lifestyle intervention significantly increased the HDL cholesterol level and reduced the cumulative incidence of the proatherogenic LDL phenotype B. At 3 years of follow-up , the use for pharmacologic therapy to achieve established goals in the intensive lifestyle group was 27 - 28 % less for hypertension and 25 % less for hyperlipidemia compared with placebo and metformin groups . Over an average of 3 years , 89 CVD events from 64 participants were positively adjudicated study wide , with no differences among treatment groups . CONCLUSIONS Lifestyle intervention improves CVD risk factor status compared with placebo and metformin therapy . Although no differences in CVD events were noted after 3 years , achieved risk factor modifications suggest that longer intervention may reduce CVD event rates BACKGROUND Venous thromboembolism ( VTE ) and cardiovascular disease ( CVD ) share some risk factors , including obesity , but it is unclear how dietary patterns associated with reduced risk of CVD relate to risk of VTE . OBJECTIVE To compare the relationships of adherence to a Dietary Approaches to Stop Hypertension (DASH)-style diet with the risks of CVD and VTE . PATIENTS / METHODS We confirmed by medical record review 1094 incident cases of CVD and 675 incident VTEs during a mean follow-up of 14.6 years in 34 827 initially healthy participants in the Women 's Health Study who completed at baseline a 133-item food frequency question naire scored for adherence to a DASH diet .  We compared estimated associations of dietary patterns with CVD and VTE from proportional hazards models in a competing risk framework . RESULTS Initial analyses adjusted for age , energy intake and r and omized treatments showed 36 - 41 % reduced hazards of CVD among women in the top two quintiles of DASH score relative to those in the bottom quintile ( P(trend ) < 0.001 ) . In multivariate analysis , women in the top two quintiles had 12 - 23 % reduced hazards of CVD relative to women in the bottom quintile ( P(trend ) = 0.04 ) . Analyses restricted to coronary events showed more variable 10 - 33 % reduced hazards in the top two quintiles ( P(trend ) = 0.09 ) . In contrast , higher DASH scores were unrelated to risk of VTE , with a 1 % reduced hazard for the top vs. bottom quintile ( P(trend ) = 0.95 ) . CONCLUSION An apparently strong association of adherence to the DASH diet with incidence of CVD was attenuated upon control for confounding variables . Adherence to the DASH diet was not associated with risk of VTE in women The Isfahan Healthy Heart Programme ( IHHP ) is a five to six year comprehensive integrated community-based programme for cardiovascular diseases ( CVD ) prevention and control via reducing CVD risk factors and improvement of cardiovascular healthy behaviour in a target population . IHHP started late in 1999 and will be finished in 2005 - 2006 . A primary survey was done to collect baseline data from interventional ( Isfahan and Najaf-Abad ) and reference ( Arak ) communities . In a two-stage sampling method , we r and omly selected 5 to 10 percent of households from r and omly selected clusters . Then individuals aged ≥19 years were selected for the survey . This way , data from 12,600 individuals ( 6300 in interventional counties and 6300 in the reference county ) was collected and stratified according to living area ( urban vs. rural ) and different age and sex groups . The sample s underwent a 30-minute interview to complete vali date d question naires containing questions on demography , socioeconomic status , smoking behaviour , physical activity , nutritional habits and other behaviour regarding CVD . Blood pressure and body mass index ( BMI ) measurements were done and fasting blood sample s were taken for two hours post load plasma glucose ( 2 hpp ) , serum ( total , HDL and LDL ) cholesterol and triglyceride levels . A twelve-lead electrocardiogram was recorded in all persons above 35 years of age . Community-wide surveillance of deaths , hospital discharges , myocardial infa rct ion and stroke registry was carried out in the intervention and control areas . Four to five years of interventions based on different categories such as mass media , community partnerships , health system involvement and policy and legislation have started in the intervention area while Arak will be followed without intervention . Considering the results of the baseline surveys . ( assessment s needed , the objectives , existing re sources and the possibility of national implementation ) the interventions were planned . They were set based on specific target groups like school children , women , work-site , health personnel , high-risk persons , and community leaders were actively engaged as decision makers . A series of teams was arranged for planning and implementation of the intervention strategies . Monitoring will be done on small sample s to assess the effect of different interventions in the intervention area . While four periodic surveys will be conducted on independent sample s to assess health behaviours related to CVD risk factors in the intervention and reference areas , the original pre-intervention subjects aged more than 35 years will be followed in both areas to assess the individual effect of interventions and outcomes like sudden death , fatal and nonfatal MI and stroke . The whole baseline survey will be repeated on the original and an independent sample in both communities at the end of the study Purpose Mediterranean-type dietary pattern has been associated with lower risk of cardiovascular ( CVD ) and other chronic diseases , primarily in Southern European population s. We examined whether Mediterranean diet score ( MDS ) is associated with total , CVD , coronary heart disease ( CHD ) and stroke mortality in a prospect i ve cohort study in three Eastern European population s. Methods A total of 19,333 male and female participants of the Health Alcohol and Psychosocial factors in Eastern Europe ( HAPIEE ) study in the Czech Republic , Pol and and the Russian Federation were included in the analysis . Diet was assessed by food frequency question naire , and MDS was derived from consumption of nine groups of food using absolute cut-offs .  Mortality was ascertained by linkage with death registers . Results Over the median follow-up time of 7 years , 1314 participants died .  The proportion of participants with high adherence to Mediterranean diet was low ( 25 % ) . One st and ard deviation ( SD ) increase in the MDS ( equivalent to 2.2 point increase in the score ) was found to be inversely associated with death from all causes ( HR , 95 % CI 0.93 , 0.88–0.98 ) and CVD ( 0.90 , 0.81–0.99 ) even after multivariable adjustment . Inverse but statistically not significant link was found for CHD ( 0.90 , 0.78–1.03 ) and stroke ( 0.87 , 0.71–1.07 ) . The MDS effects were similar in each country cohort . Conclusion Higher adherence to the Mediterranean diet was associated with reduced risk of total and CVD deaths in these large Eastern European urban population s. The application of MDS with absolute cut-offs appears suitable for non-Mediterranean population BACKGROUND Health behaviors of adults living with cardiovascular disease ( CVD ) risk factors affect additional risk , where lifestyle behavioral choices become even more important in controlling disease and preventing additional negative health outcomes . In addition , both lifestyle behaviors and CVD risk factor prevalence can vary by ethnicity . OBJECTIVE We compared multiple health behaviors of adults with diabetes , hypertension , high cholesterol , and obesity to the behaviors of adults without those conditions in a diverse ethnic sample to determine if significant differences existed between groups . METHODS Data were obtained from  30-minute r and om-digit-dial telephone surveys in 2007 ( n = 3607 ) . All data were self-reports . Healthy behaviors  included meeting recommendations for intake of fruits and vegetables ; consuming low or very low amounts of dietary fat ; eating breakfast six or seven days per week ; having a healthy diet ; and meeting recommendations for walking , moderate , and vigorous physical activity . Unhealthy behaviors included  frequent consumption of soda and fast food , smoking , binge drinking ,  and high stress .  RESULTS More than 6 % of respondents had diabetes , 15.9 % had hypertension , 16.4 % had high cholesterol , and 18.5 % were obese . Significantly fewer healthy and more unhealthy behaviors were reported for those who had CVD risk factors than were reported by those who did not have such conditions . Ethnic differences in CVD risk factor prevalence and health behaviors existed as well ( p < 0.001 ) . Logistic regression models indicated that not eating a healthy diet ( odds ratio [ OR ] = 1.82 ) was a significant predictor for diabetes ; not eating a healthy diet ( OR = 1.52 ) and not doing vigorous physical activity ( OR = 1.79 ) were significant predictors for hypertension ; consumption of high amounts of dietary fat ( OR = 1.70 ) and of fast food ( OR = 1.51 ) were significant predictors for high cholesterol levels ; and not eating a healthy diet ( OR = 1.52 ) , high consumption of dietary fat ( OR = 2.20 ) , not eating breakfast ( OR = 1.33 ) and not performing vigorous physical activity ( OR = 1.63 ) , but less consumption of fast food ( OR = 0.64 ) were significant predictors for obesity . CONCLUSIONS Specifically tailored and culturally sensitive interventions that address multiple health behaviors may be necessary for these high-risk population Background The feasibility of conducting a large-scale Polypill clinical trial in developing countries remains unclear . More information is needed regarding the efficacy in reducing the risk factors of cardiovascular disease ( CVD ) , side effects , improvement in adherence and physician/patient " acceptability " of the Polypill . Methods We conducted an open-label , parallel-group , r and omized clinical trial involving three sites in Sri Lanka that enrolled a total of 216 patients without established CVD . The trial compared a Polypill ( 75 mg aspirin , 20 mg simvastatin , 10 mg lisinopril and 12.5 mg hydrochlorothiazide ) to St and ard Practice . After r and omization , patients were followed monthly for three months . Pre-specified primary outcomes included reduction in systolic blood pressure , total cholesterol and estimated 10-year CVD risk . We also evaluated the recruitment process and acceptability of the Polypill by both physicians and patients . Results Patients were recruited in a six-month period as planned . Two hundred three patients ( 94.0 % ) completed the treatment program and returned for their three-month follow-up visits . No safety concerns were reported . These findings suggest a high rate of patient acceptability , a finding that is bolstered by the majority of patients completing the trial ( 90 % ) indicating that they would take the Polypill " for life " if proven to be effective in reducing CVD risk . Approximately 86 % of the physicians surveyed agreed with and supported use of the Polypill for primary prevention and 93 % for secondary prevention of CVD . Both the Polypill and St and ard Practice result ed in marked reductions in systolic blood pressure , total cholesterol and 10-year risk of CVD . However , the differences between the treatment groups were not statistically significant . Conclusions We successfully completed a Polypill feasibility trial in Sri Lanka . We were able to document high acceptability of the Polypill to patients and physicians . We were unable to estimate the risk factor reductions on the Polypill because the control group received similar treatment with individual drugs . The Polypill was however simpler and achieved comparable risk factor reductions , highlighting its potential usefulness in the prevention of CVD.Trial registration number Clinical trials.gov : Objective : There is indirect evidence suggesting that strawberries , containing several key nutrients , may be associated with the risk of cardiovascular disease ( CVD ) . In the Women ’s Health Study , we examined strawberry intake for both its prospect i ve association with CVD risk in 38,176 women and its cross-sectional association with lipids and C-reactive protein ( CRP ) in a subset of 26,966 women . Methods : Strawberry intake was assessed from a baseline semiquantitative food frequency question naire , along with other self-reported lifestyle , clinical and dietary factors . Participants returned baseline bloods which were assayed for lipids and CRP . We computed the relative risks ( RRs ) for total CVD ( 1,004 cases ) ( including confirmed myocardial infa rct ion , stroke , revascularization , and cardiovascular death ) occurring during 10.9 years of follow-up . Results : At baseline , 25.6 % , 41.9 % , 24.8 % , and 7.7 % of women reported corresponding strawberry intake of none , 1–3 servings/month , 1 serving/week , and ≥2 servings/week . For total CVD , the multivariate RRs ( 95 % confidence intervals ) for increasing categories of strawberry intake were 1.00 ( ref ) , 1.01 ( 0.85–1.19 ) , 0.95 ( 0.77–1.17 ) , and 1.27 ( 0.94–1.72 ) ( P , trend = 0.06 ) . We found a similar lack of an association for individual cardiovascular endpoints and comparing mean levels of lipids and CRP by category of strawberry intake . However , women consuming ≥2 servings/week versus none had a borderline significant , multivariate 14 % lower likelihood of an elevated CRP of ≥3 mg/L. Conclusions : Strawberry intake was unassociated with the risk of incident CVD , lipids , or CRP in middle-aged and older women , though higher strawberry intake may slightly reduce the likelihood of having elevated CRP levels . Additional epidemiologic data are needed to clarify any role of strawberries in CVD prevention Context Studies of the role of endogenous sex hormones in  cardiovascular disease ( CVD ) in men have been inconclusive . Contribution A total of 2084 men from 2 Framingham Heart Study cohorts had levels of  total serum estrogen , testosterone , and dehydroepi and rosterone sulfate ( DHEA-S )  measured in 1981 to 1985 for the original cohort and in 1987 to 1991 for the offspring cohort . Testosterone and DHEA-S levels were not associated with CVD risk . Estrogen levels were inversely related : Risk for CVD in the highest quartile was 0.68 ( 95 % CI , 0.50 to 0.92 ) times that in the lowest level . Caution s Investigators studied only white men and did not study free unbound hormone levels . Implication s Endogenous estrogen may be vasculoprotective in men , which is in contrast to the effects of exogenous estrogen . The Editors Male sex is an independent risk factor for cardiovascular disease ( CVD ) ( 1 ) . Scientists have postulated that the 5- to 10-year lag period in CVD incidence in women ( compared with men ) may be related to differences in endogenous sex hormones ( 27 ) . Indeed , substantial evidence suggests that sex hormones ( testosterone , estrogen , and dehydroepi and rosterone sulfate [ DHEA-S ] ) influence traditional and newer CVD risk factors ( 27 ) . Interest in the role of sex hormones in the pathogenesis of CVD has been rekindled by the observation that men with genetic defects of estrogen synthesis ( 8) or action ( 9 ) develop premature atherosclerosis . In addition , genetic variation in estrogen receptor- has been associated with prevalent CVD ( 10 , 11 ) , and and rogen and estrogen receptor expression in coronary arteries has been reported to influence coronary atherosclerosis in men ( 12 ) . In contrast to the aforementioned data , prospect i ve studies relating circulating sex hormone levels to incident CVD in men have been inconclusive . For example , low serum testosterone levels have been associated with greater progression of sub clinical atherosclerosis in 2 previous investigations ( 13 , 14 ) , but other studies have reported no association of testosterone levels with CVD events ( 1521 ) . On a parallel note , low DHEA-S levels have been linked to greater CVD risk in some studies ( 18 , 2224 ) but not in other studies ( 13 , 20 , 2529 ) . Investigations relating serum estradiol levels to CVD risk in men have generally found no statistically significant association ( 1520 ) . Some previous investigations were limited by modest sample sizes ( 14 , 17 , 18 , 22 , 25 , 26 ) ; an insufficient number of CVD events ( 1518 , 22 , 23 , 26 ) ; and , in some instances , a retrospective study design ( 1721 , 25 , 26 ) . In addition , some reports ( 15 , 22 , 24 ) focused on CVD death ( they did not evaluate nonfatal CVD events ) . Thus , a large prospect i ve community-based study relating sex hormones to CVD risk with adequate power to detect modest potential associations is needed . Accordingly , we evaluated the associations of serum levels of sex hormones that were measured at a routine baseline examination with CVD incidence in a prospect ively assembled cohort of participants . Methods Study Sample The Framingham Heart Study , a prospect i ve study of the risk factors for the development of heart disease and stroke , began in 1948 with the recruitment of 5209 men and women between 30 and 60 years of age who resided in Framingham , Massachusetts ( 30 ) . The Framingham Offspring Study began in 1971 with the recruitment of 5124 participants who were the children of the original cohort and the spouses of the children ( 31 ) . Participants in the original cohort are examined every 2 years , while offspring cohort members are assessed every 4 years . At each Framingham Heart Study examination , attendees undergo a physical examination and laboratory assessment of risk factors ( 31 ) . We evaluated 2789 men who attended the 17th biennial examination ( 19811983 ) of the original cohort or the fourth quadrennial examination ( 19871991 ) of the offspring cohort . We measured serum total testosterone and estradiol levels at these examinations , and we measured DHEA-S levels at the 18th examination ( 19831985 ) for the original cohort and at the fourth examination for the offspring cohort . We excluded 705 men because of prevalent CVD ( n= 541 ) and nonavailable testosterone data ( n= 164 ) . After exclusions , 2084 men ( 74.7 % ; 525 original cohort participants ) without previous CVD were eligible . Data on serum estradiol levels and serum DHEA-S levels were available in 2047 men and 1928 participants , respectively . All participants gave written informed consent , and the institutional review board at the Boston Medical Center approved the study protocol . Biochemical Assessment of Sex Hormones As described previously ( 32 ) , we measured total testosterone , total estradiol , and DHEA-S levels from serum sample s by using radioimmunoassays ( Diagnostic Products Corp. , Los Angeles , California ) for total testosterone ( interassay coefficient of variation , 11 % ) , total estradiol ( interassay coefficient of variation , 4 % ) , and DHEA-S ( interassay coefficient of variation , 11 % ) . We also measured serum luteinizing hormone levels at the baseline examinations ( interassay coefficient of variation , 6 % ) . Cardiovascular Outcomes All participants were under continuous surveillance for the occurrence of  CVD events and death . Participants are evaluated periodically at the Framingham Heart Study and through health history up date s between examinations ( obtained via telephone interviews ) . Three experienced investigators obtained and review ed hospitalization and physician office visit records . We defined incident CVD as coronary heart disease ( recognized or unrecognized myocardial infa rct ion , angina pectoris , coronary insufficiency , or coronary heart disease death ) , cerebrovascular disease ( stroke or transient ischemic attack ) , congestive heart failure ( by Framingham criteria ) , or peripheral vascular disease ( intermittent claudication ) . Criteria for the diagnoses of cardiovascular events have been described elsewhere ( 33 ) . We considered that an unrecognized myocardial infa rct ion occurred if we found electrocardiographic evidence of clinical ly significant loss of R waves or appearance of pathologic Q waves on serial tracings in the absence of a clinical ly recognized event ( 33 ) . We defined the follow-up period a priori as 10 years from the baseline examination ( up to 1995 for the original cohort and 2002 for the offspring cohort ) to permit equal duration s of follow-up of original and offspring cohort participants and because sex hormone levels change considerably with age ( 34 ) . The analyses that combined the original and offspring cohorts had greater statistical power and allowed us to evaluate participants over a wider age range . Statistical Analyses Serum testosterone levels were normally distributed . Serum estradiol and DHEA-S levels were skewed and were log-transformed . We examined the associations between baseline sex hormone levels and CVD incidence during follow-up ( separate analyses for each hormone ) . We chose incident CVD as the outcome because the effects of sex hormones are not limited to a given vascular territory and this maximized our statistical power and limited multiple statistical testing ( as opposed to analysis for each CVD component ) . We stratified all analyses by the cohort ( offspring cohort vs. original cohort ) . We verified that the assumption of proportionality of hazards was satisfied for each hormone . We calculated age- and multivariable-adjusted 10-year incidence rates for CVD for each hormone quartile ( 35 ) . We prespecified 2 types of models : Primary analyses evaluated the sex hormones as continuous variables to maximize statistical power ( model A ) , and additional analyses compared CVD risk in hormone quartiles 2 to 4 with that in quartile 1 ( referent ) ( model B ) . These models facilitated assessment of potential nonlinear relations . For each hormone , we used proportional hazards regression ( 36 ) that adjusted for 1 ) age alone and 2 ) age , smoking , systolic and diastolic blood pressure , antihypertensive medication use , ratio of total and high-density lipoprotein ( HDL ) cholesterol , diabetes mellitus , and body mass index ( BMI ) . We evaluated models adjusted for age alone because some risk factors may fall along the causal pathway from estradiol to CVD . Adjustment for BMI was performed because adiposity is a strong correlate of sex hormone levels ( 37 ) and of sex hormonebinding globulin ( 38 ) . Sex hormonebinding globulin strongly influences measurements of total circulating sex hormone levels and the amount of bound hormone versus free hormone . We also evaluated models without BMI as a covariate to assess whether adjustment for BMI attenuated relations of sex hormones with CVD and models that were adjusted additionally for the use of aspirin or lipid-lowering medications , alcohol consumption , and education level . We incorporated statistical interaction terms to evaluate effect modification by age , BMI , smoking status , systolic blood pressure , and total cholesterolHDL cholesterol ratio . To gain additional insights into potential nonlinearity of associations between hormone levels and CVD risk , we examined generalized additive Cox models using penalized splines ( 39 , 40 ) for hormones that were statistically significantly related to CVD risk . Because potential relationships of sex hormones to CVD risk may be mediated by the development of risk factors during follow-up , we prespecified examination of time-dependent Cox models ( updating established CVD risk factors [ covariates in the multivariable-adjusted proportional hazards regression ] every 4 years at follow-up examinations ) for analyses of any sex hormone that was statistically significantly related to CVD events in the initial analyses . Additional Analyses We performed secondary analyses relating CVD risk to the estradioltestosterone ratio ( 37 , 41 ) . In addition , we investigated whether hypogonadism was related to CVD risk . We defined hypogonadism empirically as a serum testosterone level less than 10.4 nmol/L ( 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 ) Several previous studies found that too great a reduction of clinic blood pressure ( BP ) by treatment increased cardiovascular disease ( CVD ) risk , whereas moderate reduction decreased it . Thus , it has been suggested that the relationship between BP and CVD events is J-shaped , with CVD risk decreasing as BP is lowered , and then rising as BP is further decreased . Correlation between BP level and CVD risk , however , is stronger for ambulatory BP monitoring ( ABPM ) than clinical BP measurements . We previously established that the hypertension treatment-time regimen , upon awakening versus at bedtime , exerts differential effect on BP control during the day and nighttime , which translates into a differential degree of CVD risk prevention . We , therefore , investigated the role of hypertension treatment-time scheme on the nature of the relationship between achieved clinic and ambulatory BP and CVD risk in the MAPEC ( Monitorización Ambulatoria para Predicción de Eventos Cardiovasculares , i.e. , Ambulatory Blood Pressure Monitoring for Prediction of Cardiovascular Events ) study , a prospect i ve , open-label , blinded-endpoint trial on 2156 hypertensive patients ( 1044 men/1112 women ) , 55.6 ± 13.6 ( mean ± SD ) yrs of age , r and omized to ingest all prescribed once-a-day hypertension medications upon awakening or the entire daily dose of ≥1 of them at bedtime  . Ambulatory BP was measured for 48-h at baseline and annually thereafter , and more frequently ( quarterly ) when adjustment of treatment was necessary . After a median follow-up of 5.6 yrs , a J-shaped relationship was detected between total CVD events and clinic as well as awake BP mean , but only for the group of patients ingesting all medications upon awakening . The relationship was different in the group of patients who ingested ≥1 medications at bedtime ; the risk of CVD events progressively diminished in a linear , rather than J-shaped , manner with treatment-induced decrease in awake BP mean . The adjusted hazard ratio of CVD events was significantly lower with the progressive reduction in the asleep BP mean , independent of the hypertension treatment-time regimen . There was no single major event , i.e. , CVD death , myocardial infa rct ion , or stroke , in patients who achieved an asleep systolic BP mean < 103 mm Hg . Our findings indicate that bedtime hypertension treatment is not associated with a J-shaped relationship between achieved BP and CVD risk . The decreased CVD risk associated with the progressive reduction in asleep BP , more feasible by bedtime than morning hypertension treatment , has clinical implication s , in particular , the need to consider the proper timing of hypertension medications , in conjunction with ABPM for proper assessment of BP control , as an improved and potentially safer means of reducing CVD risk of hypertensive patients . ( Author correspondence : rhermida@uvigo.es 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 Background : Health concerns have been raised about rice consumption , which may significantly contribute to arsenic exposure . However , little is known regarding whether habitual rice consumption is associated with cardiovascular disease ( CVD ) risk . Objective : We examined prospect ively the association of white rice and brown rice consumption with CVD risk . Design : We followed a total of 207,556 women and men [ 73,228 women from the Nurses ’ Health Study ( 1984–2010 ) , 92,158 women from the Nurses ’ Health Study II ( 1991–2011 ) , and 42,170 men from the Health Professionals Follow-Up Study ( 1986–2010 ) ] who were free of CVD and cancer at baseline . Vali date d semiquantitative food-frequency question naires were used to assess consumption of white rice , brown rice , and other food items . Fatal and nonfatal CVD ( coronary artery disease and stroke ) was confirmed by medical records or self-reports . Results : During 4,393,130 person-years of follow-up , 12,391 cases of CVD were identified . After adjustment for major CVD risk factors , including demographics , lifestyle , and other dietary intakes , rice consumption was not associated with CVD risk . The multivariable-adjuted HR of developing CVD comparing ≥5 servings/wk with < 1 serving/wk was 0.98 ( 95 % CI : 0.84 , 1.14 ) for white rice , 1.01 ( 0.79 , 1.28 ) for brown rice , and 0.99 ( 0.90 , 1.08 ) for total rice . To minimize the potential impact of racial difference in rice consumption , we restricted the analyses to whites only and obtained similar results : the HRs of CVD for ≥5 servings/wk compared with < 1 serving/wk were 1.04 ( 95 % CI : 0.88 , 1.22 ) for white rice and 1.01 ( 0.78 , 1.31 ) for brown rice . Conclusions : Greater habitual consumption of white rice or brown rice is not associated with CVD risk . These findings suggest that rice consumption may not pose a significant CVD risk among the U.S. population when consumed at current amounts . More prospect i ve studies are needed to explore these associations in other population CONTEXT Recent guidelines for treatment of overweight and obesity include recommendations for risk stratification by disease conditions and cardiovascular disease ( CVD ) risk factors , but the role of physical inactivity is not prominent in these recommendations . OBJECTIVE To quantify the influence of low cardiorespiratory fitness , an objective marker of physical inactivity , on CVD and all-cause mortality in normal-weight , overweight , and obese men and compare low fitness with other mortality predictors . DESIGN Prospect i ve observational data from the Aerobics Center Longitudinal Study . SETTING Preventive medicine clinic in Dallas , Tex . PARTICIPANTS A total of 25714 adult men ( average age , 43.8 years [ SD , 10.1 years ] ) who received a medical examination during 1970 to 1993 , with mortality follow-up to December 31 , 1994 . MAIN OUTCOME MEASURES Cardiovascular disease and all-cause mortality based on mortality predictors ( baseline CVD , type 2 diabetes mellitus , high serum cholesterol level , hypertension , current cigarette smoking , and low cardiorespiratory fitness ) stratified by body mass index . RESULTS During the study period , there were 1025 deaths ( 439 due to CVD ) during 258781 man-years of follow-up . Overweight and obese men with baseline CVD or CVD risk factors were at higher risk for all-cause and CVD mortality compared with normal-weight men without these predictors . Using normal-weight men without CVD as the referent , the strongest predictor of CVD death in obese men was baseline CVD ( age- and examination year-adjusted relative risk [ RR ] , 14.0 ; 95 % confidence interval [ CI ] , 9.4 - 20.8 ) ; RRs for obese men with diabetes mellitus , high cholesterol , hypertension , smoking , and low fitness were similar and ranged from 4.4 ( 95 % CI , 2.7 - 7.1 ) for smoking to 5.0 ( 95 % CI , 3.6 - 7.0 ) for low fitness . Relative risks for all-cause mortality in obese men ranged from 2.3 ( 95 % CI , 1.7 - 2.9 ) for men with hypertension to 4.7 ( 95 % CI , 3.6 - 6.1 ) for those with CVD at baseline . Relative risk for all-cause mortality in obese men with low fitness was 3.1 ( 95 % CI , 2.5 - 3.8 ) and in obese men with diabetes mellitus 3.1 ( 95 % CI , 2.3 - 4.2 ) and as slightly higher than the RRs for obese men who smoked or had high cholesterol levels . Low fitness was an independent predictor of mortality in all body mass index groups after adjustment for other mortality predictors . Approximately 50 % ( n = 1674 ) of obese men had low fitness , which led to a population -attributable risk of 39 % for CVD mortality and 44 % for all-cause mortality . Baseline CVD had population attributable risks of 51 % and 27 % for CVD and all-cause mortality , respectively . CONCLUSIONS In this analysis , low cardiorespiratory fitness was a strong and independent predictor of CVD and all-cause mortality and of comparable importance with that of diabetes mellitus and other CVD risk factors BACKGROUND It has been demonstrated in previous studies that pharmacist management of patients with type 2 diabetes mellitus ( T2DM ) in the outpatient setting not only improves diabetes-related clinical outcomes such as hemoglobin A1c but also blood pressure ( BP ) , total cholesterol ( TC ) , and quality of life . Improved control of BP and TC has been shown to reduce the risks of cardiovascular disease ( CVD ) , which has placed a heavy economic burden on the health care system . However , no study has evaluated the cost-effectiveness of pharmacist intervention programs with respect to the long-term preventive effects on CVD outcomes among T2DM patients . OBJECTIVES To ( a ) quantify the long-term preventive effects of pharmacist intervention on CVD outcomes among T2DM patients using evidence from a matched cohort study in the outpatient primary care setting and ( b ) assess the relative cost-effectiveness of adding a clinical pharmacist to the primary care team for the management of patients with T2DM based on improvement in CVD risks with the aid of an economic model . METHODS Clinical data between the periods of June 2007 to February 2010 were collected from electronic medical records at 2 separate clinics at Kaiser Permanente ( KP ) Northern California , 1 with primary care physicians only ( control group ) and the other with the addition of a pharmacist ( enhanced care group ) . Patients in the enhanced care group were matched 1:1 with patients in the control group according to baseline characteristics that included age , gender , A1c , and Charlson comorbidity score . The estimated 10-year CVD risk for both groups was calculated by the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) Risk Engine ( version 2 ) based on age , sex , race , smoking status , atrial fibrillation , duration of diabetes , levels of A1c , systolic BP ( SBP ) and TC , and high-density lipoprotein cholesterol ( HDL-C ) observed at 12 months . There was no statistical difference in the baseline clinical inputs to the Risk Engine ( A1c [ P=0.115 ] , SBP [ P=0.184 ] , TC [ P=0.055 ] , and HDL-C [ P=0.475 ] ) between the 2 groups . A Markov model was developed to simulate the estimated CVD outcomes over 10 years and to estimate cost-effectiveness . The final outcomes examined included incremental cost and effectiveness measured by life years and per quality -adjusted life year gained . Both deterministic sensitivity analysis ( SA ) and probabilistic SA were conducted to examine the robustness of the results . RESULTS The estimated risks for coronary heart disease ( CHD ) and stroke ( both nonfatal and fatal ) at the end of the follow-up were consistently lower in the enhanced care group compared with the control group , even though baseline risks in both groups were similar . The absolute risk reduction ( ARR ) between the enhanced care and control groups increased over time . For example , the ARR for nonfatal CHD risk in year 1 was 0.5 % ( 1.2 % vs. 0.7 % ) , whereas the ARR increased to 5.5 % in year 10 ( 14.8 % vs. 9.3 % ) . Similarly , the ARR between the enhanced care and the control groups was calculated as 0.3 % for fatal CHD in year 1 and increased to 4.6 % in year 10 . Results from the Markov model suggest that the enhanced care group was shown to be a dominant strategy ( less expensive and more effective ) compared with the control group in the 10-year evaluation period in the base-case ( average or mean results ) scenario . Sensitivity analysis that took into account the uncertainty in all important variables , such as wage of pharmacists , utility weight ( the degree of preference individuals have for a particular health state or condition ) , response rate to pharmacists ' care , and uncertainty associated with the estimated 10 years of CVD risk , revealed that the relative value of enhanced care was robust to most of the variations in these parameters . Notably , the level of cost-effectiveness measured by net monetary value depends on the time horizon adopted by the payers and the magnitude of CVD risk reduction . The enhanced care group has a higher chance of being considered as a cost-effective strategy when a longer time horizon such as a minimum of 4 to 5 years is adopted . CONCLUSIONS Adding pharmacists to the health care management team for diabetic patients improves the long-term CVD risks . The longer-term CVD risk reductions were shown to be more dramatic than the short-term reduction . A longer time horizon adopted by health plans in managing T2DM patients has a higher probability of making the intervention cost-effective Background —Oxidized phospholipids ( OxPL ) circulate on apolipoprotein B-100 particles ( OxPL/apoB ) , and primarily on Lp(a ) lipoprotein ( a ) [ Lp(a ) ] . The relationship of OxPL/apoB levels to future cardiovascular events is not known . Methods and Results —The Bruneck study is a prospect i ve population -based survey of 40- to 79-year-old men and women recruited in 1990 .  Plasma levels of OxPL/apoB and lipoprotein ( a ) [ Lp(a ) ]  were measured in 765 subjects in 1995 and incident cardiovascular disease ( CVD ) , defined as cardiovascular death , myocardial infa rct ion , stroke , and transient ischemic attack , was assessed from 1995 to 2005 . During the follow-up period , 82 subjects developed CVD . In multivariable analysis , which included traditional risk factors , high sensitivity C-reactive protein ( hsCRP ) , and lipoprotein-associated phospholipase A2 ( Lp-PLA2 ) activity , subjects in the highest tertile of OxPL/apoB had a significantly higher risk of cardiovascular events than those in the lowest tertile ( hazard ratio[95 % CI ] 2.4[1.3 to 4.3 ] , P=0.004 ) . The strength of the association between OxPL/apoB and CVD risk was amplified with increasing Lp-PLA2 activity ( P=0.018 for interaction ) . Moreover , OxPL/apoB levels predicted future cardiovascular events beyond the information provided by the Framingham Risk Score ( FRS ) . The effects of OxPL/apoB and Lp(a ) were not independent of each other but they were independent of all other measured risk factors . Conclusions —This study demonstrates that OxPL/apoB levels predict 10-year CVD event rates independently of traditional risk factors , hsCRP , and FRS . Increasing Lp-PLA2 activity further amplifies the risk of CVD mediated by OBJECTIVE People living with HIV infection are at increased risk for developing cardiovascular disease ( CVD ) . Safe and effective interventions for lowering CVD risk in HIV infection are high priorities . We conducted a prospect i ve , r and omized , controlled study to evaluate whether a yoga lifestyle intervention improves CVD risk factors , virological or immunological status , or quality of life ( QOL ) in HIV-infected adults relative to st and ard of care treatment in a matched control group . METHODS Sixty HIV-infected adults with mild-moderate CVD risk were assigned to 20 weeks of supervised yoga practice or st and ard of care treatment . Baseline and week 20 measures were : 2-h oral glucose tolerance test with insulin monitoring , body composition , fasting serum lipid/lipoprotein profile , resting blood pressures , CD4 T-cell count and plasma HIV RNA , and the Medical Outcomes Study Short Form (SF)-36 health-related QOL inventory . RESULTS Resting systolic and diastolic blood pressures improved more ( P=0.04 ) in the yoga group ( -5 + /- 2 and -3 + /- 1 mmHg , respectively ) than in the st and ard of care group ( + 1 + /- 2 and + 2 + /- 2 mmHg , respectively ) . However , there was no greater reduction in body weight , fat mass or proatherogenic lipids , or improvements in glucose tolerance or overall QOL after yoga . Immune and virological status was not adversely affected . CONCLUSION Among traditional lifestyle modifications , yoga is a low-cost , simple to administer , nonpharmacological , popular behavioural intervention that can lower blood pressure in pre-hypertensive HIV-infected adults with mild-moderate CVD risk factors Objective Although depression is a risk and prognostic factor for cardiovascular disease ( CVD ) , depression trials involving cardiac patients have not observed the anticipated cardiovascular benefits . To test our hypothesis that depression treatment delivered before clinical CVD onset reduces risk of CVD events , we conducted an 8-year follow-up study of the Indiana sites of the Improving Mood-Promoting Access to Collaborative Treatment ( IMPACT ) r and omized controlled trial . Methods Participants were 235 primary care patients 60 years or older with major depression or dysthymia who were r and omized to a 12-month collaborative care program involving antidepressants and psychotherapy ( 85 without and 35 with baseline CVD ) or usual care ( 83 without and 32 with baseline CVD ) . Hard CVD events ( fatal/nonfatal ) were identified using electronic medical record and Medicare/Medicaid data . Results A total of 119 patients ( 51 % ) had a hard CVD event . As hypothesized , the treatment × baseline CVD interaction was significant ( p = .021 ) . IMPACT patients without baseline CVD had a 48 % lower risk of an event than did usual care patients ( 28 % versus 47 % , hazard ratio = 0.52 , 95 % confidence interval = 0.31–0.86 ) . The number needed to treat to prevent one event for 5 years was 6.1 . The likelihood of an event did not differ between IMPACT and usual care patients with baseline CVD ( 86 % versus 81 % , hazard ratio = 1.19 , 95 % confidence interval , 0.70–2.03 ) . Conclusions Collaborative depression care delivered before CVD onset halved the excess risk of hard CVD events among older , depressed patients . Our findings raise the possibility that the IMPACT intervention could be used as a CVD primary prevention strategy . Trial Registration : clinical trials.gov Identifier : NCT01561105 Background Of all workers in Dutch construction industry , 20 % has an elevated risk of cardiovascular disease ( CVD ) . A major risk factor for CVD risk is an unhealthy lifestyle . The aim of our study is to design a lifestyle intervention for construction workers with an elevated CVD risk , and to evaluate its ( cost- ) effectiveness . Methods / Design In a RCT , 692 participants will be r and omised to either the control or the intervention group . The control group will receive usual care . For the intervention group , a lifestyle intervention has been design ed based on interviews and current literature . The intervention will last 6 months and will comprise 3 face-to-face and 4 telephone contacts , consisting of individual counselling aim ed at increasing daily physical activity ( PA ) and improving dietary behaviour , and /or smoking cessation . Counselling will take place at the Occupational Health Service ( OHS ) , and will be done according to motivational interviewing ( MI ) . Additional written information about healthy lifestyle will also be provided to those in the intervention group . At baseline , after 6 and after 12 months , measurements will take place . Primary outcome variables will be the lifestyle behaviours of concern , i.e. daily PA , dietary intake , and smoking status . Secondary outcome variables will be body mass index ( BMI ) , systolic and diastolic blood pressure , total and HDL blood cholesterol , Hba1c and cardio-respiratory fitness ( CRF ) . Sickness absenteeism and cost-effectiveness will be assessed as well . Multilevel analysis will be performed to compare all outcome measures between the intervention group and the control group . Discussion By improving lifestyle , CVD risk may be lowered , yielding benefits for both employee and employer . If proven effective , this lifestyle intervention will be implemented on a larger scale within the Occupational Health Services in construction industry . Trial registration Current Controlled Trials IS RCT BACKGROUND Increasing evidence for cardiovascular mortality among patients with psoriasis and psoriatic arthritis ( PsA )  has accumulated , together with evidence for increased prevalence of risk factors for cardiovascular disease ( CVD ) . OBJECTIVES To describe cardiovascular morbidity in PsA , determine its prevalence and identify risk factors for its development . METHODS At the University of Toronto , patients were followed up prospect ively according to a st and ard protocol , including disease-related features and comorbidities . Patients with CVD , including myocardial infa rct ion ( MI ) , angina , hypertension and cerebrovascular accident ( CVA ) , were identified . The prevalence of CVD morbidities in these patients was compared with data from the Canadian Community Health Survey through st and ardised prevalence ratios ( SPRs ) . Cox relative risk regression analysis was used to analyse risk factors . RESULTS At the time of analysis , 648 patients were registered in the data base . After clinic entry , 122 developed hypertension , 38 had an MI and 5 , 21 and 11 had CVA , angina and congestive heart failure ( CHF ) , respectively . 155 patients had at least one of these conditions . The SPRs for MI ( 2.57 ; 95 % CI 1.73 to 3.80 ) , angina ( 1.97 ; 95 % CI 1.24 to 3.12 ) and hypertension ( 1.90 ; 95 % CI 1.59 to 2.27 ) were statistically significant , whereas the SPRs for CHF ( 1.19 ; 95 % CI 0.50 to 2.86 ) and CVA ( 0.91 ; 95 % CI 0.34 to 2.43 ) were not . Factors associated with CVD included diabetes , hyperlipidaemia and high Psoriasis Area and Severity Index scores . CONCLUSION Patients with PsA  are at increased risk of cardiovascular morbidities compared with the general population . In addition to known risk factors for CVD , severe psoriasis is an important predictor in patients with OBJECTIVE The risk of cardiovascular disease ( CVD ) is increased in patients with rheumatoid arthritis ( RA ) . The objective of this study was to examine the distribution of known CVD risk factors and biomarkers of CVD in women with and without RA . METHODS This study included two components : an examination of clinical CVD risk factors among women participating in the Nurses ' Health Study , a prospect i ve longitudinal cohort , and an analysis of CVD biomarkers among a subgroup of women from this cohort who provided a blood specimen in 1989 ( biospecimen cohort ) . Data regarding clinical risk factors for CVD were collected in 1990 by mailed question naire . The diagnosis of RA was confirmed through a structured medical record abstract ion . We compared clinical risk factors for CVD and biomarkers of CVD between women with and without RA , adjusting for age , body mass index ( BMI ) , smoking status , and menopause status . RESULTS Women with RA ( n = 287 ) were significantly more likely than women without RA ( n = 87,019 ) to report no alcohol use ( 48.2 % versus 39.4 % ) and past cigarette smoking ( 47.8 % versus 38.0 % ) . No significant differences between these groups were observed for current smoker status , BMI , regular aspirin use , diabetes , hypertension , physical activity , and family history of early myocardial infa rct ion . In the biospecimen cohort ( 69 RA cases and 491 controls ) , the levels of several inflammatory biomarkers linked to CVD were significantly elevated in women with RA , including CRP , fibrinogen , sICAM-1 , sTNFRI , sTNFRII , and osteoprotegerin . Levels of total cholesterol , low-density lipoprotein , triglycerides , apolipoprotein B , and Lp(a ) were similar between groups . Levels of homocysteine were similar , but vitamin B(12 ) was significantly higher among women with RA than among the controls . CONCLUSION In women participating in the Nurses ' Health Study , most traditional CVD risk factors were similar between those who had RA and those who did not . However , as expected , biomarkers of inflammation associated with CVD were generally elevated in women with RA BACKGROUND Sub-optimal management of cardiovascular disease ( CVD ) patients is widespread in primary and secondary care , with risk factors frequently unrecorded or untreated . AIM To investigate the effectiveness of educational interventions developed in primary care , on recording , prescribing and control of risk factors among all patients recorded by their general practitioner as having CVD . DESIGN OF STUDY Factorial , duster-r and omised controlled trial . SETTING Primary care teams representing the range of practice development in a geographically defined area in inner London . METHOD Participating practice s were r and omly allocated to one of the four intervention groups : information , evidence , both or neither . Interventions were tailored to suit individual practice needs . At a mean of 19 months after baseline , and three months after the end of intervention , practice s carried out the follow-up assessment of recording , treatment , and control of risk factors in the same CVD patients . RESULTS Adequate recording of all three risk factors , found inapproximately a third of patients at baseline , increased non-significantly by 10.5 % ( 95 % confidence interval [ CI ] = 3.9 to 24.9 ) in the information ( versus not information ) group and by 6.6 % ( 95 % [ CI ] = 8.9 to 22.0 ) in the evidence ( versus not evidence ) group . Factorial improvements in prescribing and control of risk factors tended not to be significant . Adequate recording of an three risk factors showed the greatest improvement in the information plus evidence group ( 19.9 % increase , P for heterogeneity across the four groups < or = 0.001 ) . Mean change from baseline to follow-up within the four intervention groups suggested improvements in the combined information plus evidence group in cholesterol recording ( 22.5 % increase ) , prescribing of lipid lowering drugs ( 4.4 % increase ) and mean cholesterol ( 0.7 mmol/l decrease ) . CONCLUSIONS Adequate risk factor recording did not differ between the information ( versus not information ) or the evidence ( versus not evidence ) intervention groups . Combined training in information systems and evidence -based medicine should be considered in the design of future interventions , to improve secondary prevention of CVD Objective : Rheumatoid arthritis ( RA ) patients have an increased risk of developing cardiovascular diseases ( CVD ) . Other autoimmune diseases such as hypothyroidism are also associated with an enhanced risk for CVD . Our objective was to determine first , the prevalence of hypothyroid disorders in RA patients , and second , the risk of CVD in RA patients with hypothyroid abnormalities . Methods : Subjects were RA patients who participated in an ongoing prospect i ve cohort study of cardiovascular mortality and morbidity ( n = 358 ) in which hypothyroid abnormalities were assessed .  CVD was defined as a verified medical history of coronary , cerebral or peripheral arterial disease . Results : Clinical hypothyroidism was observed in 16 of 236 female RA patients ( 6.8 % ) , which is significantly higher than in the general population of The Netherl and s. Sub clinical hypothyroidism was detected in 6 out of 236 RA women ( 2.5 % ) . In female RA patients , CVD was present in 6 out of 16 ( 37.5 % ) of all hypothyroid women . The odds ratio for CVD comparing female hypothyroid RA patients with female euthyroid RA patients was 4.1 ( 95 % CI 1.2–14.3 ) after adjustment for sex , age , diabetes , smoking ( ever ) , hypertension and statin use . Conclusions : Clinical hypothyroidism was observed three times more often in female RA patients than females in the general population . In female RA patients , clinical hypothyroidism was associated with a fourfold higher risk of CVD in comparison with euthyroid female RA patients independently of the traditional risk factors OBJECTIVES To assess the risk of total and cardiovascular mortality in older adults with systolic hypertension and with a low ankle-arm index ( AAI ) as a marker of sub clinical peripheral arterial disease ( PAD ) . DESIGN Prospect i ve observational study PARTICIPANTS A subgroup of 1537 participants in the Systolic Hypertension in the Elderly Program ( SHEP ) were screened for lower extremity arterial disease using the AAI . Participants were evaluated at 4 years to determine vital status and cause of death . Total and cardiovascular disease ( CVD ) mortality rates were assessed in relationship to clinical CVD at baseline , cardiovascular risk factors and the presence of a low AAI ( sub clinical PAD ) . RESULTS Total mortality rates increased as the AAI decreased in those with and without clinical CVD at baseline . In those without clinical CVD at baseline , the presence of an AAI < or = .9 was associated with an age-adjusted relative risk ( RR ) of 3.00 for total mortality in men and 2.67 in women . Results were similar for CVD mortality and persisted after adjustment for cardiovascular risk factors including the presence of an abnormal electrocardiogram . CONCLUSIONS A low ankle arm-index predicted a two to three-fold increase in total and cardiovascular mortality in older adults with systolic hypertension of risk for incident cardiovascular disease . In this study of older adults with systolic hypertension , 19.7 % of the participants had sub clinical PAD . Risk factor modification could be targeted to older adults based on markers of asymptomatic atherosclerosis Background —Family members of patients with cardiovascular disease ( CVD ) may be at increased risk due to shared genes and lifestyle . Hospitalization of a family member with CVD may represent a “ motivational moment ” to take preventive action . Methods and Results —A r and omized , controlled clinical trial was conducted in healthy adult family members ( N=501 ; 66 % female ; 36 % nonwhite ; mean age , 48 years ) of patients hospitalized with CVD to evaluate a special intervention ( SI )  with personalized risk factor screening , therapeutic lifestyle-change counseling , and progress reports to physicians versus a control intervention ( CIN ) on the primary outcome , mean percent change in low-density lipoprotein cholesterol ( LDL-C ) , and other risk factors . Vali date d dietary assessment s and st and ardized risk factors were obtained at baseline and 1 year ( 94 % follow-up ) . At baseline , for 93 % of subjects , saturated fat comprised ≥7 % of total caloric intake , and 79 % had nonoptimal LDL-C levels ( of which 50 % were unaware ) . There was no difference in the SI versus the CIN with respect to the mean percent change in LDL-C ( −1 % versus −2 % , respectively ; P=0.64 ) , owing to a similar significant reduction in LDL-C in both groups ( −4.4 mg/dL and −4.5 mg/dL , respectively ) . Diet score significantly improved in the SI versus the CIN ( P=0.04 ) . High-density lipoprotein cholesterol declined significantly in the CIN but not in the SI ( −3.2 % [ 95 % CI , −5.1 to −1.3 ] versus + 0.3 % [ 95 % CI , −1.7 to + 2.4 ] ; P=0.01 ) . At 1 year , SI subjects were more likely than controls to exercise > 3 days per week ( P=0.04 ) . Conclusion —The SI was not more effective than the CIN in reducing the primary end point , LDL-C. The screening process identified many family members of hospitalized patients with CVD who were unaware of their risk factors , and further work is needed to develop and test interventions to reduce their CVD risk BACKGROUND The evidence for a potential benefit of antioxidant vitamins and folic acid in cardiovascular disease ( CVD ) prevention is derived from laboratory , clinical , and observational epidemiological studies but remains inconclusive . Large-scale r and omized trials with clinical end points are necessary to minimize confounding and provide unbiased estimates of the balance of benefits and risks , yet data from such trials are scarce , especially among women . METHODS The Women 's Antioxidant Cardiovascular Study ( WACS ) is a r and omized , double-blind , placebo-controlled trial testing whether antioxidant vitamins and a folic acid/vitamin B(6)/vitamin B(12 ) combination prevent future cardiovascular events among women with preexisting CVD or > or=3 CVD risk factors . This paper describes the design of the trial and baseline characteristics of participants , evaluates the success of r and omization , and addresses the generalizability of future findings . RESULTS In a factorial design , 8171 U.S. female health professionals aged > or=40 years were r and omized to vitamin E , vitamin C , beta-carotene , or placebos . Of these women , 5442 were also subsequently r and omized to folic acid/vitamin B(6)/vitamin B(12 ) or placebo . The r and omization was successful , as evidence d by similar distributions of baseline demographic , health , and behavioral characteristics across treatment groups . The clinical profile of participants was similar to that observed in another large trial of women with CVD . CONCLUSIONS The similar distribution of known potential confounders across treatment groups provides reassurance that unmeasured or unknown potential confounders are also equally distributed . Although a definitive conclusion regarding generalizability requires additional trials in diverse population s , there is little biological basis for supposing that the benefit-risk balance differs in other high-risk women Background Shared decision-making and patients ’ choice of interventions are areas of increasing importance , not least seen in the light of the fact that chronic conditions are increasing , interventions considered important for public health , and still non-acceptance of especially risk-reducing treatments of cardiovascular diseases ( CVD ) is prevalent . A better underst and ing of patients ’ medication-taking behavior is needed and may be reached by study ing the reasons why people accept or decline medication recommendations . The aim of this paper was to identify factors that may influence people ’s decisions and reasoning for accepting or declining a cardiovascular preventive medication offer . Methods From a r and om sample of 4,000 people aged 40–59 years in a Danish population , 1,169 participants were asked to imagine being at increased risk of cardiovascular disease and being offered a preventive medication . After receiving ‘ complete ’ information about effectiveness of the medication they were asked whether they would accept medication . Finally , they were asked about reasons for the decision . Results A total of 725 ( 67 % ) of 1,082 participants accepted the medication offer . Even quite large effects of medication ( up to 8 percentage points absolute risk reduction ) had a smaller impact on acceptance to medication than personal experience with cardiovascular disease . Furthermore , increasing age of the participant and living with a partner were significantly associated with acceptance . Some 45 % of the respondents accepting justified their choice as being for health reasons , and they were more likely to be women , live alone , have higher income and higher education levels . Among those who did not accept the medication offer , 56 % indicated that they would rather prefer to change lifestyle . Conclusions Medication effectiveness seems to have a moderate influence on people ’s decisions to accept preventive medication , while factors such as personal experience with cardiovascular disease may have an equally strong or stronger influence , indicating that practitioners could do well to carefully identify the reasons for their patients ’ treatment decisions BACKGROUND Studies have shown that South Asians are highly susceptible to cardiovascular diseases ( CVDs ) . There is very little information available about the prevalence of risk factors for CVD in the physician population , a group that might be expected to be more aware of cardiovascular risk and health status . AIM To evaluate the prevalence of cardiovascular risk factors - including metabolic , dietary and behavioural - among the physician population in southern India . METHODS Approximately 4000 physicians of differing specialties from eight southern districts in Tamilnadu , India , in and around the city of Madurai were listed . Of these , 1600 were r and omly selected to participate in a cross-sectional survey  , of which 1514 physicians agreed to participate . The survey included demographic question naires , objective measurements of blood pressure , fasting blood sugar , fasting lipids and waist circumference , and question naires about their dietary and behavioural habits .  RESULTS Complete data were available for 1433 physicians . Using a blood pressure cut-off value of 130/85 mmHg or higher , the study recorded a prevalence of 41 % among men and 23 % among women . On applying the International Diabetes Federation criteria for the metabolic syndrome for the South Asian population , the present study identified 49 % of female physicians and 41 % of male physicians as having the metabolic syndrome . Only 17 % were physically active . Less than one-half of them consumed vegetables . Nearly 31 % of male physicians were smokers . CONCLUSION Analysis of these data suggests that the risk for CVD and stroke is at epidemic proportions in a cohort of well-educated physicians who are in the highest quintile of income BACKGROUND Recent literature review s have question ed hostility as a risk factor for heart disease . However , controversy persists due to the rarity of large-scale prospect i ve cohort studies of initially healthy population s. METHODS We prospect ively investigated the association between hostility and  cardiovascular ( and all-cause ) mortality among 20,550 men and women , 41 - 80 years of age , participating in the European Prospect i ve Investigation into Cancer and Nutrition in Norfolk ( EPIC-Norfolk ) , United Kingdom study . Participants were recruited by post from general practice age-sex registers and subsequently attended health checks that included the assessment of coronary disease risk factors . Hostility assessment  was completed by postal question naire . RESULTS During mean follow-up of 6 years , 1284 deaths were recorded including 481 from cardiovascular disease ( CVD ) . Hostility was not associated with CVD mortality , after adjustment for age and prevalent disease , in either men ( rate ratio for a 1 SD decrease in hostility score , representing increased hostility , 1.09 ; 95 % confidence interval 0.98 - 1.22 ) or in women ( rate ratio 1.00 ; 95 % confidence interval 0.86 - 1.26 ) . Subgroup analysis suggested hostility may be associated with CVD mortality ( independent of age , prevalent disease and cigarette smoking ) for participants reporting very high hostility and for those aged less than 60 years . CONCLUSIONS Hostility was not associated with an increased risk of cardiovascular mortality in this population study of older adults OBJECTIVES This study was design ed to determine whether  erectile dysfunction ( ED )  predicts cardiovascular disease ( CVD ) beyond traditional risk factors . BACKGROUND Both ED and CVD share pathophysiological mechanisms and often co-occur . It is unknown whether ED improves the prediction of CVD beyond traditional risk factors . METHODS This was a prospect i ve , population -based study of 1,709 men ( of 3,258 eligible ) age 40 to 70 years . The ED data were measured by self-report . Subjects were followed for CVD for an average follow-up of 11.7 years . The association between ED and CVD was examined using the Cox proportional hazards regression model . The discriminatory capability of ED was examined using C statistics . The reclassification of CVD risk associated with ED was assessed using a method that quantifies net reclassification improvement . RESULTS Of the prospect i ve population , 1,057 men with complete risk factor data who were free of CVD and diabetes at baseline were included . During follow-up , 261 new cases of CVD occurred . We found ED was associated with CVD incidence controlling for age ( hazard ratio [ HR ] : 1.42 , 95 % confidence interval [ CI ] : 1.05 to 1.90 ) , age and traditional CVD risk factors ( HR : 1.41 , 95 % CI : 1.05 to 1.90 ) , as well as age and Framingham risk score ( HR : 1.40 , 95 % CI : 1.04 to 1.88 ) . Despite these significant findings , ED did not significantly improve the prediction of CVD incidence beyond traditional risk factors . CONCLUSIONS Independent of established CVD risk factors , ED is significantly associated with increased CVD incidence . Nonetheless , ED does not improve the prediction of who will and will not develop CVD beyond that offered by traditional risk factors AIMS To examine the performance of ' the Framingham 's general CVD algorithm ' in estimating 5-year risk of cardiovascular disease ( CVD ) and coronary heart disease ( CHD )  in an adult Middle Eastern community . METHODS In a population -based prospect i ve cohort , the Tehran Lipid and Glucose Study ( TLGS ) , CVD risk estimates were calculated for 3838 individuals ( 2183 women ) free of CVD at baseline . RESULTS Over 8.6 years , there were 119 CVD ( 106 CHD ) events among women , and 164 ( 137 ) among men aged ≥ 30 years . St and ard risk factors [ age , systolic blood pressure ( SBP ) , antihypertensive treatment , total and high-density lipoprotein cholesterol , smoking and diabetes mellitus ] , measured at baseline , were significantly related to the incidence of CVD . The only exception , lack of significance for coefficients of SBP among women , was attributable to collinearity between age and SBP . For most risk factors , hazard ratios ( HRs ) for CVD were similar for the TLGS and the Framingham cohorts ' participants . Few exceptions were lower HR for SBP among TLGS ' women and lower HR for age among TLGS ' men . The Framingham equations quite correctly discriminated participants [ C statistic : CVD , 0.818 ( women ) and 0.774 ( men ) ; CHD : 0.822 ( women ) and 0.751 ( men ) ] with good calibration ( all calibration χ(2 ) values < 15 , ps > 0.1 ) . DISCUSSION AND CONCLUSIONS The Framingham 's CVD algorithm was effective at ranking individuals and could be used to quantify risk and to guide preventive care in Iranian adults . For regions without established cohort , recalibration using risk factors and CVD ( CHD ) rates may be an effective method to develop CVD ( CHD ) risk prediction algorithms for local practice Objectives : To develop a cardiovascular risk assessment tool that is feasible and easy to use in primary care ( general practice ( GP ) model ) . Design : Prospect i ve cohort study . Setting : 23 towns in the United Kingdom . Participants : 3582 women aged 60 to 79 years who were free of coronary heart disease ( CHD ) at entry into the British Women ’s Heart and Health Study . Main outcome measures : Predictive performance of a GP model compared with the st and ard Framingham model for both CHD and cardiovascular disease ( CVD ) . Results : The Framingham tool predicted CHD events over 5 years accurately ( predicted 5.7 % , observed 5.5 % ) but overpredicted CVD events ( predicted 10.5 % , observed 6.8 % ) . In higher-risk groups , Framingham overpredicted both CHD and CVD events and was poorly calibrated for this cohort . Including C-reactive protein and fibrinogen with st and ard Framingham risk factors did not improve discrimination of the model . The GP model , which used age , systolic blood pressure , smoking habit and self-rated health ( all of which can be easily obtained in one surgery visit ) performed as well as the Framingham risk tool : area under the receiver operating curve discrimination statistic was 0.66 ( 95 % confidence interval ( CI ) 0.62 to 0.70 ) for CHD and 0.67 ( 95 % CI 0.64 to 0.71 ) for CVD compared with 0.65 ( 95 % CI 0.61 to 0.68 ) and 0.66 ( 95 % CI 0.62 to 0.69 ) for the corresponding Framingham models . Conclusions : An alternative risk assessment based on only a simple routine examination and a small number of pertinent questions may be more useful in the primary care setting . This model appears to perform well but needs to be tested in different population AIMS To assess the cardiovascular disease ( CVD ) risk of people with screen-detected Type 2 diabetes and to estimate the risk reduction achievable through early intensive pharmacological intervention . METHODS In ADDITION-Cambridge , diabetic patients were identified among people aged 40 - 69 years through a stepwise screening procedure including a risk score , r and om and fasting capillary blood glucose , HbA(1c ) and oral glucose tolerance test . In those without prior macrovascular disease , 10-year CVD risk was computed using UK Prospect i ve Diabetes Study ( UKPDS ) and Framingham engines . The absolute risk reduction achievable and its plausible range were predicted using relative risk reductions for individual therapies from published trials and sensitivity analysis . RESULTS Of the 867 individuals with undiagnosed diabetes , 19 % had pre-existing CVD , 97 % were overweight or obese , 86 % had hypertension , 75 % had dyslipidaemia , 20 % had microalbuminuria and 18 % were smokers . Of those with hypertension , 35 % were not prescribed drugs and 42 % were suboptimally treated . Of participants with dyslipidaemia , 68 % were not prescribed medications and 22 % were poorly controlled . Median 10-year CVD risk was 34.0%[interquartile range ( IQR ) 26.2 - 44.6 ] in men and 21.5 % ( IQR 15.7 - 28.7 ) in women using the UKPDS engine ; 38.6 % ( IQR 27.8 - 53.0 ) in men and 24.6 % ( IQR 17.2 - 32.9 ) in women using Framingham equations . In the most conservative scenario ( no additive effect of therapies ) , the absolute risk reduction achievable through multifactorial therapy ranged from 4.9 to 9.5 % ( UKPDS ) and from 5.4 to 10.5 % ( Framingham ) . The corresponding ranges of numbers needed to treat were 11 - 20 and 10 - 19 . CONCLUSIONS People with screen-detected diabetes have an adverse cardiovascular risk profile , which is potentially modifiable through application of existing treatment recommendations 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 The aim of this study was to provide reliable information on dyslipidaemias , to estimate the trend of the prevalence of dyslipidaemias and other selected cardiovascular disease ( CVD ) risk factors at population level , and to evaluate the risk of all-cause and CVD mortality in relation to presence of mixed dyslipidaemias and other CVD risk factors . Methods Data from the five surveys ( 1983–2008 ) are presented . A r and om sample of 9,209 subjects aged 45–64 was selected for statistical analysis . During follow-up there were 1653 death cases from any cause , 864 deaths from CVD . Estimates of hazard ratios ( HR ) and 95 % confidence intervals ( CI ) were based on the multivariate Cox proportional hazards regression for all-cause mortality and CVD mortality . Results During 25 year period the prevalence of normal total cholesterol level ( < 5.2 mmol/L ) significantly increased only in women ; triglycerides and high density lipoprotein ( HDL ) cholesterol did not change in men and women . Findings in our longitudinal study showed that in men and women mixed dyslipidaemias ( HDL cholesterol < 1.03 mmol/L plus triglycerides ≥1.70 mmol/L ) significantly increased the risk for all-cause and CVD mortality ( respectively in men HR = 1.30 ; HR = 1.15 , in women HR = 1.83 ; HR = 2.13 ) . These mixed dyslipidaemia combinations combination with the other risk factors such as arterial hypertension , high fasting glucose level increased all-cause and CVD mortality risk in men and women ; while , these mixed dyslipidaemias plus smoking increased all-cause and CVD mortality risk only in men compared to never smokers without these dyslipidaemias ( respectively HR = 1.89 ; HR = 1.92 ) ; and these dyslipidaemias plus obesity increased all-cause and CVD mortality risk in women ( respectively HR = 2.25 ; HR = 2.39 ) and CVD mortality risk in men ( HR = 1.72 ) , as compared to responders without obesity and these dyslipidaemias . Conclusion Mixed dyslipidaemias ( reduced HDL cholesterol plus elevated triglycerides ) significantly increased the risk for all-cause and CVD mortality in this Lithuanian population aged 45–64 years BACKGROUND Many strategies have been evaluated to improve the prevention and control of cardiovascular ( CVD ) risk factors . Nursing telephonic and tele-counseling individualized lifestyle educational programs have been found to improve blood pressure control and adherence to lifestyle recommendation . This study tested the efficacy of a nurse-led reminder program through email ( NRP-e ) to improve CVD risk factors among hypertensive adults . METHODS All participants received usual CVD prevention and a guideline -based educational program . Subjects in the NRP-e group also received weekly email alerts and phone calls from a nurse care manager for 6 months . Emails contained a reminder program on the need for adherence with a healthy lifestyle based upon current guidelines . Follow-up visits were scheduled at 1 , 3 and 6 months after enrollment ; r and omization was made central ly and blood sample s were evaluated into a single laboratory . RESULTS The final sample consisted of 98 ( control ) and 100 ( NRP-e ) subjects ( mean age 59.0 ± 14.5 years ; 51.0 % males ) . After 6 months , the following CVD risk factors significantly improved in both groups : body mass index , alcohol and fruit consumption , cigarette smoking , adherence to therapy hours , systolic and diastolic blood pressure , fasting blood glucose , low-density lipoproteins ( LDL ) and total cholesterol , triglycerides , and physical activity . In the NRP-e group , however , the prevalence of several behaviors or conditions at risk decreased significantly more than in the control group : obesity ( -16 % ) , low fruit consumption ( -24 % ) , uncontrolled hypertension ( -61 % ) , LDL ( -56 % ) , and total cholesterol ( -40 % ) . CONCLUSIONS The NRP-e improved a range of CVD risk factors . The program had low costs , required only an average of < 20 min per day in addition to normal practice , and may deserve further evaluation for the inclusion among existing care management approaches BACKGROUND R and omized trials have largely failed to support an effect of antioxidant vitamins on the risk of cardiovascular disease ( CVD ) . Few trials have examined interactions among antioxidants , and , to our knowledge , no previous trial has examined the individual effect of ascorbic acid ( vitamin C ) on CVD . METHODS The Women 's Antioxidant Cardiovascular Study tested the effects of ascorbic acid ( 500 mg/d ) , vitamin E ( 600 IU every other day ) , and beta carotene ( 50 mg every other day ) on the combined outcome of myocardial infa rct ion , stroke , coronary revascularization , or CVD death among 8171 female health professionals at increased risk in a 2 x 2 x 2 factorial design . Participants were 40 years or older with a history of CVD or 3 or more CVD risk factors and were followed up for a mean duration of 9.4 years , from 1995 - 1996 to 2005 . RESULTS A total of 1450 women experienced 1 or more CVD outcomes . There was no overall effect of ascorbic acid ( relative risk [ RR ] , 1.02 ; 95 % CI , 0.92 - 1.13 [ P = .71 ] ) , vitamin E ( RR , 0.94 ; 95 % CI , 0.85 - 1.04 [ P = .23 ] ) , or beta carotene ( RR , 1.02 ; 95 % CI , 0.92 - 1.13 [ P = .71 ] ) on the primary combined end point or on the individual secondary outcomes of myocardial infa rct ion , stroke , coronary revascularization , or CVD death . A marginally significant reduction in the primary outcome with active vitamin E was observed among the prespecified subgroup of women with prior CVD ( RR , 0.89 ; 95 % CI , 0.79 - 1.00 [ P = .04 ] ; P value for interaction , .07 ) . There were no significant interactions between agents for the primary end point , but those r and omized to both active ascorbic acid and vitamin E experienced fewer strokes ( P value for interaction , .03 ) . CONCLUSION There were no overall effects of ascorbic acid , vitamin E , or beta carotene on cardiovascular events among women at high risk for CVD BACKGROUND Statins are prescribed for patients with cardiovascular disease ( CVD ) , along with the recommendation of adopting healthy diets . We evaluated the independent and the combined effect of statins and Mediterranean diet ( MD ) towards mortality risk in patients with previous CVD by using real-life data from a population -based prospect i ve cohort . METHODS Longitudinal analysis on 1180 subjects ( mean age 67.7 ± 10 ) with prior CVD at enrollment in the Moli-sani Study and followed up for 7.9 y ( median ) .  Adherence to MD was appraised by a Mediterranean diet score .  Hazard ratios ( HR ) with 95 % confidence intervals ( 95 % CI ) were calculated by multivariable Cox regression and competing risk models . RESULTS Multivariable risk estimates associated with a 2-point increase in MD score were 0.84 ( 95 % CI 0.70 - 1.00 ) , 0.77 ( 0.61 - 0.97 ) and 0.70 ( 0.52 - 0.93 ) for overall , cardiovascular and coronary artery disease (CAD)/cerebrovascular deaths , respectively  . Statins were not associated with death risk . Subjects combining statins and average-high adherence to MD had much lower than expected risk of cardiovascular and CAD/cerebrovascular mortality ( p for interaction = 0.045 and 0.0015 , respectively ) as compared to those neither using statins nor having average-high MD . The combination of average-high MD and statins was associated in a likely synergistic way with reduced low- grade inflammation , but not with blood cholesterol . CONCLUSIONS MD lowered the risk of all-cause , cardiovascular and CAD/cerebrovascular mortality CVD patients , net of statins . In the same population , statins  reduced CVD death risk only in combination with MD . Low- grade inflammation , rather than lipids , is likely to be on the pathway of the interaction between MD and statins towards mortality risk OBJECTIVE The objective of this study was to examine the effects of an integrated , multi-component , school-based intervention programme on cardiovascular disease ( CVD ) risk factors among a multi-ethnic cohort of middle school students . METHODS HEALTHY was a cluster r and omized , controlled , primary prevention trial . Middle school was the unit of r and omization and intervention . Half of the schools were assigned to an intervention programme consisting of changes in the total school food environment and physical education classes , enhanced by educational outreach and behaviour change activities and promoted by a social marketing campaign consisting of reinforcing messages and images . Outcome data reported ( anthropometrics , blood pressure and fasting lipid levels ) were collected on a cohort of students enrolled at the start of 6th grade ( ∼11 - 12 years old ) and followed to end of 8th grade ( ∼13 - 14 years old ) . RESULTS Forty-two middle schools were enrolled at seven field centres ; 4363 students provided both informed consent and CVD data at baseline and end of study . The sample was 52.7 % female , 54.5 % Hispanic , 17.6 % non-Hispanic Black , 19.4 % non-Hispanic White and 8.5 % other racial/ethnic combinations , and 49.6 % were categorized as overweight or obese ( body mass index ≥ 85th percentile ) at baseline . A significant intervention effect was detected in the prevalence of hypertension in non-Hispanic Black and White males . The intervention produced no significant changes in lipid levels . CONCLUSIONS The prevalence of some CVD risk factors is high in minority middle school youth , particularly males . A multi-component , school-based programme achieved only modest reductions in these risk factors ; however , promising findings occurred in non-Hispanic Black and White males with hypertension BACKGROUND Although multivitamins are widely used by US adults , few prospect i ve studies have investigated their association with the long- and short-term risks of cardiovascular disease ( CVD ) . OBJECTIVE The aim of this study was to investigate how multivitamin use is associated with the risk of CVD in initially healthy men at baseline . METHODS We studied 18,530 male physicians aged ≥40 y from the Physicians ' Health Study I cohort who were free of CVD and cancer at baseline ( 1982 ) . All men provided a wide range of self-reported lifestyle and clinical factors plus intake of selected foods and dietary supplements  . Cox proportional hazards models were used to calculate multivariable-adjusted HRs ( 95 % CIs ) . RESULTS During a mean follow-up of 12.2 y ( total of 225,287 person-years ) , there were 1697 incident cases of major CVD ( defined as nonfatal myocardial infa rct ion , nonfatal stroke , and CVD death ) . In multivariable-adjusted analyses , no significant associations were observed among baseline multivitamin users compared with nonusers for the risk of major CVD events ( HR : 0.94 ; 95 % CI : 0.84 , 1.05 ) , whereas a self-reported duration of ≥20 y at baseline was associated with lower risk ( HR : 0.56 ; 95 % CI : 0.35 , 0.90 ; P-trend = 0.05 ) . Baseline multivitamin use was also significantly inversely associated with the risk of cardiac revascularization ( HR : 0.86 ; 95 % CI : 0.75 , 0.98 ) . Baseline use of multivitamins was not significantly associated with other CVD endpoints . CONCLUSION In this long-term prospect i ve study in initially healthy men , multivitamin use for ≥20 y was associated with a lower risk of major CVD events AIM Informing a person of their individual risk of developing a disease in the future may be sufficient to provide the person with the impetus to adopt risk reducing behaviours . The aim of this study was to determine if a personalised 10-year cardiovascular disease ( CVD ) risk estimate can increase  physical activity  and other risk reduction behaviours in adults at high risk of CVD . METHODS Pilot 2 × 2 factorial r and omised controlled trial conducted in Oxfordshire , UK including 194 adults at increased CVD risk ( 10-year CVD risk ≥ 20 % ) recruited from four general practice s. Main outcome measure at one month was physical activity measured by accelerometer . RESULTS Median ( IQR ) age was 62.3 ( 54.9 , 66.1 ) years , 67 % were men and 19 % had known diabetes . Mean ( SD ) total accelerometer counts per day was 297 × 10(-3 ) ( 110 × 10(-3 ) ) and activity of moderate or greater intensity was undertaken for 53 ( 22 ) minutes per day . In the 185 ( 95 % ) participants attending follow-up an increase in physical activity was not seen . There was a non-significant 0.5 % ( p = 0.56 ) greater increase in accelerometer counts in those receiving personalised CVD risk estimates . No significant within or between group changes were seen at one month in estimated 10-year CVD risk . A net 7 % decrease in mean LDL cholesterol ( p = 0.004 ) was seen in the intervention group despite similar increases in new prescriptions for lipid lowering therapies . CONCLUSION In adults at increased risk of CVD provision of personalised 10-year CVD risk estimates did not appear to increase physical activity or estimated CVD risk over a one-month period BACKGROUND Flavonoids are plant-based phytochemicals with cardiovascular protective properties . Few studies have comprehensively examined flavonoid classes in relation to cardiovascular disease mortality . OBJECTIVE We examined the association between flavonoid intake and  cardiovascular disease ( CVD ) mortality among participants in a large , prospect i ve US cohort . DESIGN In 1999 , a total of 38,180 men and 60,289 women in the Cancer Prevention Study II Nutrition Cohort with a mean age of 70 and 69 y , respectively , completed question naires on medical history and lifestyle behaviors  , including a 152-item food-frequency question naire . Cox proportional hazards modeling was used to calculate multivariate-adjusted hazard RRs and 95 % CIs for associations between total flavonoids , 7 flavonoid classes , and CVD mortality . RESULTS During 7 y of follow-up , 1589 CVD deaths in men and 1182 CVD  deaths in women occurred . Men and women with total flavonoid intakes in the top ( compared with the bottom ) quintile had a lower risk of fatal CVD ( RR : 0.82 ; 95 % CI : 0.73 , 0.92 ; P-trend = 0.01 ) . Five flavonoid classes-anthocyanidins , flavan-3-ols , flavones , flavonols , and proanthocyanidins-were individually associated with lower risk of fatal CVD ( all P-trend < 0.05 ) . In men , total flavonoid intakes were more strongly associated with stroke mortality ( RR : 0.63 ; 95 % CI : 0.44 , 0.89 ; P-trend = 0.04 ) than with ischemic heart disease ( RR : 0.90 ; 95 % CI : 0.72 , 1.13 ) . Many associations appeared to be nonlinear , with lower risk at intakes above the referent category . CONCLUSIONS Flavonoid consumption was associated with lower risk of death from CVD . Most inverse associations appeared with intermediate intakes , suggesting that even relatively small amounts of flavonoid-rich foods may be beneficial In addition to the inverse association of dietary lycopene with various cancers , studies suggest a role for lycopene in cardiovascular disease ( CVD ) prevention . We determined whether the intake of lycopene or tomato-based foods is associated with the risk of CVD in a prospect i ve cohort of 39,876 middle-aged and older women initially free of CVD and cancer . Participants completed a food-frequency question naire and provided self-reports of coronary risk factors . Dietary lycopene levels were divided into quintiles , and primary lycopene food sources ( total tomato-based products , including tomatoes , tomato juice , tomato sauce and pizza ) were categorized . During 7.2 y of follow-up , 719 CVD cases ( including myocardial infa rct ion , stroke , revascularization and CVD death ) occurred . Compared with women in the 1st quintile of lycopene , those in increasing quintiles had multivariate relative risks ( RR ) of CVD of 1.11 , 1.14 , 1.15 and 0.90 ( P for trend = 0.34 ) . For the consumption of tomato-based products , women consuming 1.5 to < 4 , 4 to < 7 , 7 to < 10 and > or=10 servings/wk had RR ( 95 % CI ) of CVD of 1.02 ( 0.82 - 1.26 ) , 1.04 ( 0.82 - 1.31 ) , 0.68 ( 0.49 - 0.96 ) and 0.71 ( 0.42 - 1.17 ) ( P for trend = 0.029 ) compared with women consuming < 1.5 servings/wk . Among lycopene food sources , those in the highest levels of tomato sauce ( > or=2 servings/wk ) and pizza intake ( > or=2 servings/wk ) , with multivariate RR of 0.76 ( 0.55 - 1.05 ) and 0.66 ( 0.37 - 1.18 ) , respectively , had potential reductions in CVD risk . Dietary lycopene was not strongly associated with the risk of CVD . However , the possible inverse associations noted for higher levels of tomato-based products , particularly tomato sauce and pizza , with CVD suggest that dietary lycopene or other phytochemicals consumed as oil-based tomato products confer cardiovascular benefits Background Many studies have demonstrated a gap between guidelines for the prevention of cardiovascular disease ( CVD ) and their implementation in clinical practice . Aim The PEGASE education program has been devised with an aim to improve the management of patients at high risk of CVD . Methods In a multicentre study carried out from 2001–2004 in France , 96 participating physicians were r and omized into a “ trained ”  group , which included 398 “ educated ” patients , and a  “ non-trained ” group  , which included 242 “ non-educated ” patients . Educated patients received six hospital-based educational sessions , four collective and two individual .  Framingham score , smoking , lipid levels , glycaemia , blood pressure , dietary intake and drug compliance , as well as quality of life , were evaluated at baseline ( M0 ) and 6 months ( M6 ) . The primary endpoint of the study was the efficacy of the PEGASE program in reducing global CVD risk in high-risk patients . Results The Framingham score was calculated for 473 patients .  The Framingham score improved significantly at M6 vs M0 in the educated group ( 13.0 ± 8.21 vs 13.6 ± 8.48 , d = −0.658 , p = 0.016 ) , but not in the non-educated group ( 12.5 ± 8.19 vs 12.4 ± 7.81 , d = + 0.064 , p = 0.836 ) ; the mean change between the two groups did not reach significance . Quality of life , LDL-c level and diet scores improved in the “ educated ” group only . Conclusions The PEGASE education program  improved risk factors for CVD , although global assessment by Framingham score was not significantly different between groups . This program , aim ed at meeting needs and expectations of patients and physicians , was easily implemented in all hospital centres Background Physical activity ( PA ) promotes cardiovascular health and health related quality of life ( HRQoL ) , although the effect of that on blood pressure ( BP ) control has rarely been studied in hypertensive subjects . Our aim was to evaluate the effectiveness of a PA intervention programme on cardiovascular disease ( CVD ) risk , HRQoL and BP control  in hypertensive subjects . Methods A r and omized clinical trial , with a PA intervention programme of 9 months duration , comprising a walking group of 120 min/week , supervised , and with socio-cultural activities .  Participants were 207 hypertensive subjects ( 68.2 years , 76.8 % women ) .  PA ( IPAQ-s ) , diet , CVD risk , BP , BMI , smoking , and HRQoL ( SF-36 ) were assessed at baseline and at the end of the intervention . Changes in CVD risk and in HRQoL during the intervention was calculated ( end-baseline score ) . Multivariate models were applied . Results In multivariate models , the PA intervention programme , with no modification of the diet , decreased CVD risk ( − 1.19 points ) and the systolic BP ( − 8.68 mmHg ) , and increased some areas of HRQoL ( 4.45 to 14.62 points ) . An increase in the percentage of subjects with controlled BP was observed by the PA programme itself ( OR 5.395 to 5.785 according to multivariate models ) , and by the changes during the intervention in the decrease in CVD risk ( OR 0.609 ) and in the increase in the HRQoL in physical component summary ( OR 1.041 ) , role physical ( OR 1.010 ) , and bodily pain ( OR 1.014 ) , independently of controlled BP at baseline . Conclusions This PA intervention programme  improved cardiovascular health and HRQoL , and favoured BP control in primary care users with hypertension . Trial registration Clinical trials.gov ID NCT02767739 ; Trial registered on May 5th , 2016 . Retrospectively registered Background The Preventive Cardiology Center compared two intensities of behavior modification for cardiovascular disease ( CVD ) risk factors in persons at risk and their families . Characteristics of drop-outs both before and after intervention were compared with subjects who completed the 6-month trial . Methods A total of 333 individuals of all ages were enrolled in the study and r and omly assigned by family to a single-session ( ‘ skills ’ group — low-intensity ) or a five-session ( ‘ practice ’ group — high intensity ) intervention . Baseline and follow-up assessment s included a personal and family health question naire , nutritional intake survey , and clinic visit to obtain blood pressure , lipids , and height and weight data . Results Two hundred and forty adults over 18 years of age were r and omly assigned to one of the two intervention groups , Of these , 68 subjects ( 28.3 % ) did not participate in the intervention . Multivariate analysis revealed that these ‘ early drop-outs ’ were significantly more likely to be non-white and to have had a lower LDL cholesterol . Of the 172 subjects attending the intervention , 70 ( 40.7 % ) did not attend the 6-month follow-up ( ‘ late drop-outs ’ ) , Multivariate analysis revealed that , compared with follow-up attendees , non-attendees were significantly more likely to be white and to be current smokers . Conclusions Both early and late drop-outs in a r and omized trial of CVD risk reduction were significantly different than continuing participants in several key factors . These differences suggest the use of caution in both interpreting and making generalizations about behavioral trials of risk factor reduction when attrition is high 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 Diets rich in fruits and vegetables have been of interest because of their potential health benefits against chronic diseases such as cardiovascular disease ( CVD ) and cancer . The aim of this work was to assess the association of the dietary intake of a food group that includes fruits , berries and vegetables with all-cause , CVD-related and non-CVD-related mortality .  The subjects were Finnish men aged 42 - 60 y examined in 1984 - 1989 in the prospect i ve Kuopio Ischaemic Heart Disease Risk Factor ( KIHD ) Study .  Dietary intakes were assessed by 4-d food intake record during the baseline phase of the KIHD Study . The risk of all-cause and non-CVD-related deaths was studied in 2641 men and the risk of CVD-related death in 1950 men who had no history of CVD at baseline . During a mean follow-up time of 12.8 y , cardiovascular as well as noncardiovascular and all-cause mortality were lower among men with the highest consumption of fruits , berries and vegetables . After adjustment for the major CVD risk factors , the relative risk for men in the highest fifth of fruit , berry and vegetable intake for all-cause death , CVD-related and non-CVD-related death was 0.66 [ 95 % confidence interval ( CI ) 0.50 - 0.88 ] , 0.59 ( 0.33 - 1.06 ) , and 0.68 ( 0.46 - 1.00 ) , respectively , compared with men in the lowest fifth . These data show that a high fruit , berry and vegetable intake is associated with reduced risk of mortality in middle-aged Finnish men . Consequently , the findings of this work indicate that diets that are rich in plant-derived foods can promote longevity The objective was to assess whether pediatric risk factors predict cardiovascular disease ( CVD ) , impaired fasting glucose ( IFG ) + type 2 diabetes mellitus ( T2DM ) , and high blood pressure ( HBP ) in young adulthood . We performed a prospect i ve follow-up of 909 public-parochial suburban schoolchildren first studied at ages 6 to 18 years and 26 years later at a mean age of 38 years .  Pediatric triglycerides ( TGs ) , blood pressure , low-density lipoprotein cholesterol , body mass index , and glucose above and high-density lipoprotein cholesterol below established pediatric cutoffs , along with race , cigarette smoking , family history of CVD , T2DM , and HBP , were assessed as determinants of young adult CVD , a composite variable including IFG + T2DM and HBP . By stepwise logistic regression , adult CVD ( 19 yes , 862 no ) was associated with pediatric high TG ( odds ratio [ OR ] , 5.85 ; 95 % confidence interval [ CI ] , 2.3 - 14.7 ) . High TG in pediatric prob and s with young adult CVD was familial and was associated with early CVD in their high-TG parents . Adult IFG + T2DM ( 114 yes , 535 no ) was associated with parental T2DM ( OR , 2.2 ; 95 % CI , 1.38 - 3.6 ) , high childhood glucose ( OR , 4.43 ; 95 % CI , 2 - 9.7 ) , and childhood cigarette smoking ( OR , 1.64 ; 95 % CI , 1.03 - 2.61 ) . Adult HBP ( 133 yes , 475 no ) was associated with pediatric high body mass index ( OR , 2.7 ; 95 % CI , 1.7 - 4.3 ) and HBP ( OR , 2.5 ; 95 % CI , 1.5 - 4.3 ) . Pediatric risk factors are significantly , independently related to young adult CVD , IFG + T2DM , and HBP . Identification of pediatric risk factors for CVD  , IFG + T2DM , and HBP facilitates initiation of primary prevention programs to reduce development of adult CVD , IFG + T2DM , and HBP CONTEXT For women , impact of cardiovascular risk factors measured in young adulthood , particularly favorable ( low-risk ) profile , on mortality has been difficult to assess due to low short-term death rates . OBJECTIVE To assess the relationship of baseline coronary risk factor status to mortality from coronary heart disease ( CHD ) , cardiovascular diseases ( CVDs ) , and all causes in young women . DESIGN Prospect i ve cohort study . SETTING AND PARTICIPANTS A total of 7302 women aged 18 to 39 years without prior CHD or major electrocardiographic abnormalities screened between 1967 and 1973 for the Chicago Heart Association Detection Project in Industry . Risk groups were defined using national guidelines for values of systolic and diastolic blood pressure , serum cholesterol level , body mass index , presence of diabetes , and smoking status . Participants were divided into 4 groups : low risk , 0 risk factors high but 1 or more unfavorable , 1 only risk factor high , and 2 or more risk factors high . MAIN OUTCOME MEASURES All-cause mortality , CHD mortality , and CVD mortality ; hazard ratio of outcome measures comparing low-risk group with other groups . RESULTS Only 20 % met low-risk criteria ; 59 % had high levels of 1 or more risk factors . During an average follow-up of 31 years , there were 47 CHD deaths , 94 CVD deaths , and 469 deaths from all causes . The age-adjusted CVD death rate per 10,000 person-years was lowest for low-risk women and increased with the number of risk factors , ie , 1.5 , 1.7 , 5.0 , and 9.1 for low-risk ; 0 , 1 , and 2 or more risk factors high , respectively . Multivariate-adjusted CVD mortality hazard ratio for low-risk women was 0.19 ( 95 % confidence interval , 0.08 - 0.45 ) compared with women with 2 or more risk factors high . Similar patterns were observed for CHD and all-cause mortality and for both blacks and whites . CONCLUSION For women with favorable levels for all 5 major risk factors at younger ages , CHD and CVD are rare ; long-term and all-cause mortality are much lower compared with others Background Because of a high cardiovascular disease ( CVD ) risk in people with Familial Hypercholesterolemia ( FH ) , early prevention of cardiovascular disease is important for health gain and cost reduction . This project focuses on the development and evaluation of an innovative intervention aim ing to reduce CVD risk by promoting a healthy lifestyle among people with FH . Methods This project is design ed as a r and omised controlled trial in which individuals with FH will be assigned r and omly to a control or intervention group . In the intervention group ( n = 200 ) , participants will receive a personalized intervention which is a combination of web-based tailored lifestyle advice and personal counselling by a lifestyle coach .  The control group ( n = 200 ) will receive care as usual . Primary outcomes are biological indicators of CVD risk : systolic blood pressure , glucose , BMI , waist circumference and lipids ( triglycerides , total , LDL and HDL cholesterol ) . Secondary outcomes are : healthy lifestyle behaviour ( with regard to smoking , physical activity , dietary pattern and compliance to statin therapy ) and psychological correlates and determinants of healthy lifestyle behaviour ( knowledge , attitude , risk perception , social influence , self-efficacy , cues to action , intention and autonomy ) . Measurement will take place at baseline , and at 3 and 12 months after r and omisation . Additionally , a throughout process-evaluation will be conducted to assess and monitor intervention implementation during the trial . Discussion Results of the PRO-FIT project will provide information about the effects and implementation of a healthy lifestyle intervention for individuals with FH . Our experiences with this intervention will be indicative about the suitability , feasibility and benefits of this approach for future interventions in other high-risk groups , such as Familial Combined Hypercholesterolemia ( FCH ) and diabetes . Trial registration Background Cardiovascular diseases ( CVD ) are the leading cause of death and the third cause of disability in Europe . Prevention programmes should include interventions aim ed at a reduction of medical risk factors ( hypertension , hypercholesterol , hyperglycemia , overweight and obesity ) as well as behavioural risk factors ( sedentary lifestyle , high fat intake and low fruit and vegetable intake , smoking ) . The aim of this study is to investigate the effects of a multifaceted , multidisciplinary electronic prevention programme on cardiovascular risk factors . Methods / Design In a r and omized controlled trial , one group will receive a maximal intervention  (= intervention group ) . The intervention group will be compared to the control group receiving a minimal intervention .  An inclusion of 350 patients in total , with a follow-up of 3 years is foreseen . The inclusion criteria are age between 25–65 and insured by the Onderlinge Ziekenkas , insuring for guaranteed income in case of illness for self-employed . The maximal intervention group receives several prevention consultations by their general practitioner ( GP ) using a new type of cardiovascular risk calculator with personalised feedback on behavioural risk factors . These patients receive a follow-up with intensive support of health behaviour change via different methods , i.e. a tailored website and personal advice of a multidisciplinary team ( psychologist , physiotherapist and dietician ) . The aim of this strategy is to reduce cardiovascular risk factors according to the guidelines . The primary outcome measures will be cardiovascular risk factors . The secondary outcome measures are cardiovascular events , quality of life , costs and incremental cost effectiveness ratios . The control group receives prevention consultations using a new type of cardiovascular risk calculator and general feedback . Discussion This trial incorporates interventions by GPs and other health professionals aim ing at a reduction of medical and behavioural cardiovascular risk factors . An assessment of clinical , psychological and economical outcome measures will be performed . Trial registration IS RCT Background A healthy diet , low in saturated fat and high in fiber , is a popular medical recommendation in preventing cardiovascular disease ( CVD ) . One approach to motivating healthier eating is to raise individuals ’ awareness of their CVD risk and then help them form specific plans to change . Objectives The aim was to explore the combined impact of a Web-based CVD risk message and a fully automated planning tool on risk perceptions , intentions , and saturated fat intake changes over 4 weeks . Methods Of the 1187 men and women recruited online , 781 were r and omly allocated to one of four conditions : a CVD risk message , the same CVD risk message paired with planning , planning on its own , and a control group . All outcome measures were assessed by online self-reports . Generalized linear modeling was used to analyze the data . Results Self-perceived consumption of low saturated fat foods ( odds ratio 11.40 , 95 % CI 1.86–69.68 ) and intentions to change diet ( odds ratio 21.20 , 95 % CI 2.6–172.4 ) increased more in participants allocated to the planning than the control group . No difference was observed between the four conditions with regard to percentage saturated fat intake changes . Contrary to our expectations , there was no difference in perceived and percentage saturated fat intake change between the CVD risk message plus planning group and the control group . Risk perceptions among those receiving the CVD risk message changed to be more in line with their age ( change in slopeindividual = 0.075 , P = .01 ; change in slopecomparative = 0.100 , P = .001 ) , whereas there was no change among those who did not receive the CVD risk message . Conclusion There was no evidence that combining a CVD risk message with a planning tool reduces saturated fat intake more than either alone . Further research is required to identify ways in which matching motivational and volitional strategies can lead to greater behavior changes . Trial Registration International St and ard R and omized Controlled Trial Number ( IS RCT N ) : 91154001 ; http://www.controlled-trials.com/IS RCT N91154001 ( Archived by WebCite at http://www.webcitation.org/62sBoGeOO Background It is hypothesized that in individuals without clinical cardiovascular disease ( CVD ) , but at increased CVD risk , a 50 % to 60 % reduction in CVD risk could be achieved using fixed dose combination ( FDC ) therapy ( usually comprised of multiple blood‐pressure agents and a statin [ with or without aspirin ] ) in a single “ polypill ” . However , the impact of a polypill in preventing clinical CV events has not been evaluated in a large r and omized controlled trial . Methods TIPS‐3 is a 2x2x2 factorial r and omized controlled trial that will examine the effect of a FDC polypill on major CV outcomes in a primary prevention population . This study aims to determine whether the Polycap ( comprised of atenolol , ramipril , hydrochlorothiazide , and a statin )  reduces CV events in persons without a history of CVD , but who are at least at intermediate CVD risk . Additional interventions in the factorial design of the study will compare the effect of ( 1 ) aspirin versus placebo on CV events ( and cancer ) , ( 2 ) vitamin D versus placebo on the risk of fractures , and ( 3 ) the combined effect of aspirin and the Polycap on CV events . Results The study has r and omized 5713 participants across 9 countries . Mean age of the study population is 63.9 years , and 53 % are female . Mean INTERHEART risk score is 16.8 , which is consistent with a study population at intermediate CVD risk . Conclusion Results of the TIP‐3 study will be key to determining the appropriateness of FDC therapy as a strategy in the global prevention of CVD Background Cardiovascular disease ( CVD ) is the leading cause of death worldwide . Secondary prevention is essential , but participation rates for cardiac rehabilitation are low . Furthermore , current programmes do not accomplish that patients with CVD change their lifestyle in a way that their individual risk factors for recurrent events decrease , therefore more effective interventions are needed . In this study , the effectiveness of the Hartcoach-programme , a telephonic secondary prevention program focussing on self management , is studied . Methods / design A multicenter , r and omised parallel-group study is being conducted . Participants are 400 patients with acute myocardial infa rct ion ( STEMI , NSTEMI , ) and patients with chronic or unstable angina pectoris ( IAP ) . Patients are recruited through the participating hospitals and r and omly assigned to the experimental group ( Hartcoach-programme plus usual care ) or the control group ( usual care).The Hartcoach-programme consists of a period of six months during which the coach contacts the patient every four to six weeks by telephone . Coaches train patients to take responsibility for the achievement and maintenance of the defined target levels for their particular individual modifiable risk factors . Target levels and treatment goals are agreed by the nurse and patient together . Data collection is blinded and occurs at baseline and after 26 weeks ( post-intervention ) . Primary outcome is change in cardiovascular risk factors ( cholesterol , body mass index , waist circumference , blood pressure , physical activity and diet ) . Secondary outcomes include chances in glucose , HbA1c , medication adherence , self-management and quality of life . Discussion This study evaluates the effects of the Hartcoach-programme on the reduction of individual risk factors of patients with CVDs . Patients who are not invited to follow a hospital based rehabilitation programme or patients who are unable to adhere to such a programme , may be reached by this home based Hartcoach-programme . If positive results are found , the implementation of the Hartcoach-programme will be extended , having implication s for the management of many people with CVD.Trial registration Overweight and obesity are major contributors to both type 2 diabetes and cardiovascular disease ( CVD ) . Moreover , individuals with type 2 diabetes who are overweight or obese are at particularly high risk for CVD morbidity and mortality . Although short-term weight loss has been shown to ameliorate obesity-related metabolic abnormalities and CVD risk factors , the long-term consequences of intentional weight loss in overweight or obese individuals with type 2 diabetes have not been adequately examined . The primary objective of the Look AHEAD clinical trial is to assess the long-term effects ( up to 11.5 years ) of an intensive weight loss program delivered over 4 years in overweight and obese individuals with type 2 diabetes . Approximately 5000 male and female participants who have type 2 diabetes , are 45 - 74 years of age , and have a body mass index > or=25 kg/m(2 ) will be r and omized to one of the two groups . The intensive lifestyle intervention is design ed to achieve and maintain weight loss through decreased caloric intake and increased physical activity . This program is compared to a control condition given diabetes support and education . The primary study outcome is time to incidence of a major CVD event . The study is design ed to provide a 0.90 probability of detecting an 18 % difference in major CVD event rates between the two groups . Other outcomes include components of CVD risk , cost and cost-effectiveness , diabetes control and complications , hospitalizations , intervention processes , and quality of life BACKGROUND With few exceptions , tools used to estimate cardiovascular disease ( CVD ) risk in those without prior events are based mainly on data from middle-aged subjects . Given the ever increasing number of older people , many with hypertension , a risk score relevant to this group is warranted . Our aim was to develop a cardiovascular risk equation suitable for risk prediction in elderly , hypertensive population s. METHODS We utilized  cardiovascular end point data from 4.1 years median follow-up in 5,426 hypertensive subjects without previous CVD from the Second Australian National Blood Pressure Study ( ANBP2 ) . Our risk model , based on Cox regression , was developed using 75 % of subjects without evident CVD ( n = 4,072 ) , r and omly selected and stratified by age and gender , and internally vali date d using the remaining 25 % . The model was also externally vali date d against the Dubbo Study data set . RESULTS The final model included sex , age , physical activity in the 2 weeks prior to entry into study , family history , use of anticoagulants , central ly acting antihypertensive agents or diabetes medication , and an interaction term for sex and diabetes medication . The C-statistic was 0.65 ( 0.62 - 0.67 ) for our predictive model on the model development data set and 0.62 ( 0.57 - 0.67 ) on the internal validation data set . The Dubbo Data C-statistic for CVD was 0.68 ( 95 % CI 0.65 - 0.71 ) . CONCLUSIONS All models performed similarly . Because of greater ease of implementation , we recommend that existing algorithms be extended into older age groups Background — There is growing awareness of cardiovascular disease ( CVD ) as the leading cause of death in women , but whether this greater awareness is associated with increased action by women to lower their personal or family ’s risk is unknown . Methods and Results — A nationally representative sample of 1008 women selected through r and om-digit dialing were given a st and ardized question naire about history of CVD/risk factors , awareness of leading cause of death , knowledge of healthy and personal levels of CVD risk factors , self-reported actions taken to reduce risk  , and barriers to heart health . The rate of awareness of CVD as the leading cause of death has nearly doubled since 1997 ( 55 % versus 30 % ) was significantly greater for whites compared with blacks and Hispanics ( 62 % versus 38 % and 34 % , respectively ) and was independently correlated with increased physical activity ( odds ratio , 1.35 ; 95 % CI , 1.00 to 1.83 ) and weight loss ( odds ratio , 1.47 ; 95 % CI , 1.14 to 2.02 ) in the previous year in logistic regression models . Fewer than half of the respondents were aware of healthy levels of risk factors . Awareness that personal level was not healthy was positively associated with action . Most women took steps to lower risk in family members and themselves . The most frequently cited barriers for heart health were confusion in the media ( 49 % ) , the belief that health is determined by a higher power ( 44 % ) , and caretaking responsibilities ( 36 % ) . Conclusions — General awareness of CVD risk among women is associated with preventive action . Educational interventions need to be targeted at racial/ethnic minority women Most patients with type 2 diabetes mellitus develop cardiovascular disease ( CVD ) , with substantial loss of life expectancy . Nonfatal CVD contributes greatly to excess healthcare costs and decreased quality of life in patients with diabetes . The current epidemic of obesity has raised expectations that CVD associated with type 2 diabetes will become an even greater public health challenge . Despite the importance of this health problem , there is a lack of definitive data on the effects of the intensive control of glycemia and other CVD risk factors on CVD event rates in patients with type 2 diabetes . The Action to Control Cardiovascular Risk in Diabetes ( ACCORD ) trial is a r and omized , multicenter , double 2 x 2 factorial design study involving 10,251 middle-aged and older participants with type 2 diabetes who are at high risk for CVD events because of existing CVD or additional risk factors . ACCORD is testing the effects of 3 medical treatment strategies to reduce CVD morbidity and mortality . All participants are in the glycemia trial , which is testing the hypothesis that a therapeutic strategy that targets a glycosylated hemoglobin ( HbA1c ) level of < 6.0 % will reduce the rate of CVD events more than a strategy that targets an HbA1c level of 7.0%-7.9 % . The lipid trial includes 5,518 of the participants , who receive either fenofibrate or placebo in a double-masked fashion to test the hypothesis of whether , in the context of good glycemic control , a therapeutic strategy that uses a fibrate to increase high-density lipoprotein cholesterol and lower triglyceride levels together with a 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor ( statin ) to lower low-density lipoprotein cholesterol will reduce the rate of CVD events compared with a strategy that uses a statin plus a placebo . The blood pressure trial includes the remaining 4,733 participants and tests the hypothesis that a therapeutic strategy that targets a systolic blood pressure of < 120 mm Hg in the context of good glycemic control will reduce the rate of CVD events compared with a strategy that targets a systolic blood pressure of < 140 mm Hg . The primary outcome measure for all 3 research questions is the first occurrence of a major CVD event , specifically nonfatal myocardial infa rct ion , nonfatal stroke , or cardiovascular death . Upon the expected completion of participant follow-up in 2009 , the ACCORD trial should document for the first time the benefits and risks of intensive glucose control , intensive blood pressure control , and the combination of fibrate and statin drugs in managing blood lipids in high-risk patients with type 2 diabetes
There is uncertainty whether current strategies for providing CVD risk scores  affect CVD events .
Providing CVD risk scores may slightly reduce CVD risk factor levels and may increase preventive medication prescribing in higher-risk people without evidence of harm .
BACKGROUND The current paradigm for cardiovascular disease ( CVD ) emphasises absolute risk assessment to guide treatment decisions in primary prevention .
Although the derivation and validation of multivariable risk assessment tools , or CVD risk scores , have attracted considerable attention , their effect on clinical outcomes is uncertain .
OBJECTIVES To assess the effects of evaluating and providing CVD risk scores in adults without prevalent CVD on cardiovascular outcomes , risk factor levels , preventive medication prescribing , and health behaviours .