A Markov model of the cost-effectiveness of pharmacist care for diabetes in prevention of cardiovascular diseases: evidence from Kaiser Permanente Northern California. Rationale and Design of the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) Study 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). World Salt Awareness Week. The Effectiveness of Pharmacist Interventions on Cardiovascular Risk: The Multicenter Randomized Controlled RxEACH Trial. Global Risk Assessment to Guide Blood Pressure Management in Cardiovascular Disease Prevention Effectiveness-based guidelines for the prevention of cardiovascular disease in women--2011 update: a guideline from the American Heart Association. Effectiveness of Dader Method for pharmaceutical care on control of blood pressure and total cholesterol in outpatients with cardiovascular disease or cardiovascular risk: EMDADER-CV randomized controlled trial. The systematic coronary risk evaluation (SCORE) for the prevention of cardiovascular diseases. Does evidence exist for its effectiveness? A systematic review The relationship of fibrinogen and factors VII and VIII to incident cardiovascular disease and death in the elderly: results from the cardiovascular health study. Information and Risk Modification Trial (INFORM): design of a randomised controlled trial of communicating different types of information about coronary heart disease risk, alongside lifestyle advice, to achieve change in health-related behaviour Sun, vitamin D, and cardiovascular disease. Long-term cardiovascular mortality among middle-aged men with gout. An integrated general practice and pharmacy-based intervention to promote the use of appropriate preventive medications among individuals at high cardiovascular disease risk: protocol for a cluster randomized controlled trial What level of physical activity protects against premature cardiovascular death? The Caerphilly study A cardiovascular disease policy model that predicts life expectancy taking into account socioeconomic deprivation e-Care for heart wellness: a feasibility trial to decrease blood pressure and cardiovascular risk. High Diet Quality Is Associated with a Lower Risk of Cardiovascular Disease and All-Cause Mortality in Older Men123 Diuretic versus alpha-blocker as first-step antihypertensive therapy: final results from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Nut Consumption in Relation to Cardiovascular Disease Incidence and Mortality Among Patients With Diabetes Mellitus Improving diabetes care: multi-component cardiovascular disease risk reduction strategies for people with diabetes in South Asia--the CARRS multi-center translation trial. White blood cell count and cardiovascular disease. Insights from the Framingham Study. 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 Predictors of heart rate variability and its prognostic significance in chronic kidney disease. Vitamin supplement use in a low-risk population of US male physicians and subsequent cardiovascular mortality. Favorable cardiovascular risk profile in young women and long-term risk of cardiovascular and all-cause mortality. Low intake of fruits, berries and vegetables is associated with excess mortality in men: the Kuopio Ischaemic Heart Disease Risk Factor (KIHD) Study. Sarcopenic Obesity and Risk of Cardiovascular Disease and Mortality: A Population-Based Cohort Study of Older Men Tracking Women’s Awareness of Heart Disease: An American Heart Association National Study Cardiovascular disease risk reduction in rural China: a clustered randomized controlled trial in Zhejiang A Promotores de Salud Intervention to Reduce Cardiovascular Disease Risk in a High-Risk Hispanic Border Population, 2005-2008 C-reactive protein and risk of cardiovascular disease in men and women from the Framingham Heart Study. Global, Regional, and National Burden of Cardiovascular Diseases for 10 Causes, 1990 to 2015 Risk functions for prediction of cardiovascular disease in elderly Australians: the Dubbo Study. The AUStralian MEDiterranean Diet Heart Trial (AUSMED Heart Trial): A randomized clinical trial in secondary prevention of coronary heart disease in a multiethnic Australian population: Study protocol. National Study of Women’s Awareness, Preventive Action, and Barriers to Cardiovascular Health Endogenous Sex Hormones and Cardiovascular Disease Incidence in Men Evaluation of cardiovascular risk predicted by different SCORE equations: The Netherlands as an example The South Asian Heart Lifestyle Intervention (SAHELI) study to improve cardiovascular risk factors in a community setting: design and methods. The Heartfile Lodhran CVD Prevention Project- end of Project Evaluation Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone: the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). ALLHAT Collaborative Research Group. Potato consumption and risk of cardiovascular disease: 2 prospective cohort studies. Cardiovascular Outcomes in High-Risk Hypertensive Patients Stratified by Baseline Glomerular Filtration Rate
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 —Medication errors and adverse drug events are common after hospital discharge due to changes in medication regimens , suboptimal discharge instructions , and prolonged time to follow-up . Pharmacist-based interventions may be effective in promoting the safe and effective use of medications , especially among high-risk patients such as those with low health literacy . Methods and Results —The Pharmacist Intervention for Low Literacy in Cardiovascular Disease ( PILL-CVD ) study is a r and omized controlled trial conducted at 2 academic centers — V and erbilt University Hospital and Brigham and Women 's Hospital . Patients admitted with acute coronary syndrome or acute decompensated heart failure were r and omly assigned to usual care or intervention . The intervention consisted of pharmacist-assisted medication reconciliation , inpatient pharmacist counseling , low-literacy adherence aids , and tailored telephone follow-up after discharge . The primary outcome is the occurrence of serious medication errors in the first 30 days after hospital discharge . Secondary outcomes are health care utilization , disease-specific quality of life , and cost-effectiveness .  Enrollment was completed September 2009 . A total of 862 patients were enrolled , and 430 patients were r and omly assigned to receive the intervention . Analyses will determine whether the intervention was effective in reducing serious medication errors , particularly in patients with low health literacy . Conclusions —The PILL-CVD study was design ed to reduce serious medication errors after hospitalization through a pharmacist-based intervention . The intervention , if effective , will inform health care facilities on the use of pharmacist-assisted medication reconciliation , inpatient counseling , low-literacy adherence aids , and patient follow-up after discharge . Clinical Trial Registration — clinical trials.gov . Identifier : NCT00632021 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 Cardiovascular disease ( CVD ) , including stroke , heart attack and heart failure , is the leading cause of death and disability worldwide . Raised blood pressure ( BP ) is a major cause of CVD , responsible for 62 % of stroke and 49 % of coronary heart disease cases . There is much evidence for a causal relationship between salt intake and BP . The current salt intake in many countries around the world is between 9 g ⁄d and 12 g ⁄d ( ie , 3.6–4.8 g of sodium ) . R and omized trials have demonstrated that a modest reduction in salt intake lowers BP in individuals with raised BP and also in those with ‘ ‘ normal ’ ’ BP . Furthermore , there is a dose-response relationship . Within the range of 12 g ⁄d to 3 g ⁄d , the lower the salt intake , the lower the BP . Because raised BP throughout its range is a major cause of CVD , salt reduction would reduce cardiovascular risk . It was estimated that a reduction of 6 g ⁄d in salt intake would reduce stroke by 24 % and coronary heart disease by 18 % . This would prevent approximately 35,000 stroke and coronary heart disease deaths a year in the United Kingdom and approximately 2.5 million deaths worldwide . Both prospect i ve studies and outcome trials have demonstrated that a lower salt intake is related to a reduced risk of CVD .  Salt reduction is one of the most cost-effective interventions to reduce CVD in both developed and developing countries . For example , the UK salt reduction campaign , which result ed in a fall in salt intake by approximately 10 % ( ie , from 9.5 g ⁄d in 2003 to 8.6 g ⁄d by May 2008 ) , cost just £ 15 million and led to approximately 6000 fewer CVD deaths per year , saving the UK economy approximately £ 1.5 billion per annum according to the recent report by the UK government ’s health advisory agency , the National Institute for Health and Clinical Excellence . In most developed countries , approximately 80 % of salt consumed is added to foods at the stage of manufacturing , and the consumers have no say over how much salt is added . Therefore , to achieve a reduction in population salt intake , it is imperative that the food industry make a gradual and sustained reduction in the amount of salt that is added to all foods . This approach has been successful in the United Kingdom and is now being exp and ed worldwide . World Salt Awareness Week was introduced by the salt reduction action group World Action on Salt and Health ( WASH ) in 2008 . The event serves as a platform for international experts in the fields of hypertension and nephrology to raise the profile of the importance of salt reduction to both the public and health professionals worldwide 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 ) 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 Substantial progress has been made in the awareness , treatment , and prevention of  cardiovascular disease ( CVD ) in women since the first women-specific clinical recommendations for the prevention of CVD were published by the American Heart Association ( AHA ) in 1999.1 The myth that heart disease is a “ man 's disease ” has been debunked ; the rate of public awareness of CVD as the leading cause of death among US women has increased from 30 % in 1997 to 54 % in 2009.2 The age-adjusted death rate result ing from  coronary heart disease ( CHD ) in females , which accounts for about half of all CVD deaths in women , was 95.7 per 100 000 females in 2007 , a third of what it was in 1980.3,4 Approximately 50 % of this decline in CHD deaths has been attributed to reducing major risk factors and the other half to treatment of CHD including secondary preventive therapies.4 Major r and omized controlled clinical trials such as the Women 's Health Initiative have changed the practice of CVD prevention in women over the past decade.5 The investment in combating this major public health issue for women has been significant , as have the scientific and medical achievements . Despite the gains that have been made , considerable challenges remain . In 2007 , CVD still caused ≈1 death per minute among women in the United States.6 These represent 421 918 deaths , more women 's lives than were cl aim ed by cancer , chronic lower respiratory disease , Alzheimer disease , and accidents combined.6 Reversing a trend of the past 4 decades , CHD death rates in US women 35 to 54 years of age now actually appear to be increasing , likely because of the effects of the obesity epidemic.4 CVD rates in the United States are significantly higher for black females compared with their white counterparts ( 286.1/100 000 versus BACKGROUND Although some studies have demonstrated that pharmacist intervention can improve drug therapy among patients with cardiovascular disease ( CVD ) , more evidence derived from r and omized controlled trials ( RCTs ) is needed , including assessment of the effect of community pharmacist interventions in patients with CVD . OBJECTIVE To assess the effectiveness of the Dader Method for pharmaceutical care on achieving therapeutic goals for blood pressure ( BP ) , total cholesterol ( TC ) , and both BP and TC ( BP/TC ) in patients with CVD and /or high or intermediate cardiovascular ( CV ) risk attending community pharmacies in Spain . METHODS Patients aged 25 to 74 years attending community pharmacies with a prescription for at least 1 drug indicated for CVD or CV risk factors were r and omized to 2 groups : an intervention group that received pharmaceutical care , which was provided by specially trained pharmacists working in collaboration with physicians , and a control group that received usual care ( routine dispensing counseling ) and verbal and written counseling regarding CVD prevention .  Patients were recruited from December 2005 to September 2006 , and both groups were followed for 8 months . Study outcomes were assessed at baseline and at 16 and 32 weeks after r and omization . The primary outcome measures were the proportions of patients achieving BP , TC , and BP/TC therapeutic goals ( BP lower than 140/90 mm Hg for patients with uncomplicated hypertension and lower than 130/80 mm Hg for patients with diabetes , chronic kidney disease , or history of myocardial infa rct ion or stroke ; TC lower than 200 mg per dL for patients without CVD and lower than 175 mg per dL for patients with CVD ) . Secondary outcomes were mean BP and TC values . BP was assessed manually by the pharmacist after a 10-minute rest in the supine position . This measurement was performed twice for every participant , and the average of the 2 measurements was calculated . TC was measured by the pharmacist during the study visit using the enzymatic dry method . Statistical analyses were performed using 2-tailed McNemar tests , Pearson chi-square tests , and Student 's t-tests ; P < 0.05 was considered statistically significant . RESULTS 714 patients were included in the study ( 356 intervention , 358 control ) , and the mean [ SD ] age was 62.8 [ 8.1 ] years . The 2 groups were similar at baseline in clinical and demographic characteristics , including the proportion of patients at therapeutic goals for BP , TC , and BP/TC . After 8 months of follow-up , there were statistically significant differences in favor of pharmaceutical care in the proportions of patients who achieved therapeutic goals for BP ( 52.5 % vs. 43.0 % , P=0.017 ) , TC ( 56.5 % vs. 44.1 % , P=0.001 ) , and BP/TC ( 37.1 % vs. 21.8 % , P < 0.001 ) . CONCLUSION Compared with usual care plus written education , pharmaceutical care focused on patient evaluation and follow-up in collaboration with physicians improved the achievement of BP , TC , and BP/TC treatment goals in patients with CVD and /or high or intermediate CV risk attending community pharmacies in Spain 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 Little is known about the prospect i ve associations of fibrinogen , factor VII , or factor VIII with  cardiovascular disease ( CVD ) and mortality in the elderly . At baseline in the Cardiovascular Health Study ( 5888 white and African American men and women ; aged > /=65 years ) , we measured  fibrinogen , factor VIII , and factor VII .  We used sex-stratified stepwise Cox survival analysis to determine relative risks ( RRs ) for CVD events and all-cause mortality ( up to 5 years of follow-up ) , both unadjusted and adjusted for CVD risk factors and sub clinical CVD . After adjustment , comparing the fifth quintile to the first , fibrinogen was significantly associated in men with coronary heart disease events ( RR=2.1 ) and stroke or transient ischemic attack ( RR=1.3 ) , and also with mortality within 2.5 years of follow-up ( RR=5.8 ) and later ( RR=1.7 ) . Factor VIII was significantly associated in men with coronary heart disease events ( RR=1.5 ) and mortality ( RR=1.8 ) , and in women with stroke/transient ischemic attack ( RR=1.4 ) . For both factors , values were higher in those who died , whether causes were CVD-related or non-CVD-related , but highest in CVD death . Factor VII exhibited associations with incident angina ( RR=1.44 ) in men and with death in women ( RR , middle quintile compared with first=0.66 ) . However , in general , factor VII was not consistently associated with CVD events in this population . We conclude that , if confirmed in other studies , the measurement of fibrinogen and /or factor VIII may help identify older individuals at higher risk for CVD events and mortality 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 Globally , cardiovascular disease ( CVD ) is the number one cause of death , being responsible for approximately 30 % of deaths worldwide . Urbanization and a westernized lifestyle are thought to play a major role in the development of CVD . There is accumulating evidence that vitamin D is a nonclassical risk factor for CVD . The active vitamin D metabolite , 1,25-dihydroxyvitamin D , which is synthesized from its precursor 25-hydroxyvitamin D ( 25[OH]D ) , down-regulates several negative and up-regulates various protective pathways in the heart and vasculature . First r and omized trials demonstrate that vitamin D supplementation leads to vasodilatation and suppresses cardiovascular risk markers such as triglycerides and the inflammation marker tumor necrosis factor-α . Solar UV-B radiation is the major source of vitamin D for humans . Consequently , the vitamin D status is largely influenced by season , geographic latitude , daily outdoor activities , and the percentage of body surface exposed to solar UV-B. A significant proportion of individuals in Europe and North America have  vitamin D concentrations in the deficiency range ( 25[OH]D<25 nmol/l ) . Available data indicate that low solar UV-B exposure and /or low 25(OH)D concentrations are associated with an increased risk of CVD . Large nonr and omized studies indicate that CVD mortality is more than twice as high in older individuals with deficient 25(OH)D concentrations compared with those individuals who have adequate 25(OH)D concentrations ( > 75 nmol/l ) . Together , experimental and epidemiological evidence does support a plausible role for improving vitamin D status in CVD prevention in the population at large . Nevertheless , future r and omised clinical trials are needed to evaluate whether vitamin D is effective with respect to primary , secondary , and /or tertiary prevention of CVD BACKGROUND There are limited data available on the association of gouty arthritis ( gout ) in middle age with long-term cardiovascular disease ( CVD ) mortality . METHODS We performed a 17-year follow-up study of 9105 men , aged 41 to 63 years and at above-average risk for coronary heart disease , who were r and omized to the Multiple Risk Factor Intervention Trial and who did not die or have clinical or electrocardiographic evidence of coronary artery disease during the 6-year trial .  Risk of CVD death and other causes subsequent to the sixth annual examination associated with gout was assessed by means of Cox proportional hazards regressions . RESULTS The unadjusted mortality rates from CVD among those with and without gout were 10.3 per 1000 person-years and 8.0 per 1000 person-years , respectively , representing an approximately 30 % greater risk . After adjustment for traditional risk factors , use of diuretics and aspirin , and serum creatinine level , the hazard ratio ( gout vs no gout ) for coronary heart disease mortality was 1.35 ( 95 % confidence interval [ CI ] , 1.06 - 1.72 ) . The hazard ratio for death from myocardial infa rct ion was 1.35 ( 95 % CI , 0.94 - 1.93 ) ; for death from CVD overall , 1.21 ( 95 % CI , 0.99 - 1.49 ) ; and for death from any cause , 1.09 ( 95 % CI , 1.00 - 1.19 ) ( P = .04 ) . The association between hyperuricemia and CVD was weak and did not persist when analysis was limited to men with hyperuricemia without a diagnosis of gout . CONCLUSION Among middle-aged men , a diagnosis of gout accompanied by an elevated uric acid level imparts significant independent CVD mortality risk . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00000487 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 Objective : To examine the optimal intensity of leisure time physical activity ( LTPA ) to decrease the risk of all cause , cardiovascular disease ( CVD ) , and coronary heart disease ( CHD ) mortality in a population sample of middle aged British men . Design : Prospect i ve study of middle aged men with an 11 year follow up . Setting : A whole population sample of men from Caerphilly , South Wales , UK . Subjects : 1975 men aged 49–64 years without historical or clinical evidence of CHD at baseline examination . Main outcome measures : All cause , CVD , and CHD mortality . Results : Total ( cumulative ) LTPA had a grade d , significant relation with all cause , CVD , and CHD mortality but no trend with cancer deaths . When different intensities of activity were considered , light and moderate intensity LTPA had inconsistent and non-significant relations with all cause , CVD , or CHD mortality whether adjusted only for age or for other cardiovascular risk factors . In contrast a significant dose – response relation was found for heavy intensity LTPA for all cause , CVD , and CHD mortality fully adjusted for other risk factors . Conclusions : These data suggest that , in a population of men without evidence of CHD at baseline , only leisure exercise classified as heavy or vigorous was independently associated with reduced risk of premature death from CVD 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 BACKGROUND Pharmacist- or nurse-led team care decreases  patient blood pressure ( BP ) and cardiovascular disease ( CVD ) risk . PURPOSE To evaluate whether a Web-based dietitian-led ( WD ) team care intervention was feasible and result ed in decreased BP , CVD risk , and weight compared to usual care ( UC ) . METHODS Electronic health record ( EHR ) data identified patients aged 30 - 69 years with BMI > 26 , elevated BP , and 10%-25 % 10-year Framingham CVD risk who were registered patient website users . Patients with uncontrolled BP at screening were r and omized to UC or WD , which included a home BP monitor , scale , and dietitian team care . WD participants had a single in-person dietitian visit to obtain baseline information and create a plan to reduce CVD risk . Planned follow-up occurred via secure messaging to report BP , weight , and fruit and vegetable intake and receive ongoing feedback . If needed , dietitians encouraged patients and their physicians to intensify antihypertensive and lipid-lowering medications . Primary outcomes were change in systolic BP and weight loss ≥4 kg at 6 months . Feasibility outcomes included intervention utilization and satisfaction . RESULTS Between 2010 and 2011 , a total of 90 of 101 participants completed 6-month follow-ups . The WD group had higher rates of secure messaging utilization and patient satisfaction . The WD group lost significantly more weight than the UC group ( adjusted net difference=-3.2 kg , 95 % CI=-5.0 , -1.5 , p<0.001 ) and was more likely to lose ≥4 kg ( adjusted relative risk [RRadj]=2.96 , 95 % CI=1.16 , 7.53 ) . BP control and CVD risk reduction were greater in WD than UC , but differences were not statistically significant . CONCLUSIONS WD intervention was feasible and result ed in decreased weight , BP , and CVD risk . A larger trial is justified . TRIAL REGISTRATION NUMBER Trial Registration Number : NCT01077388 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 The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial ( ALLHAT ) was a r and omized , double-blind , active , controlled clinical trial conducted to determine whether newer antihypertensive agents , including doxazosin , an alpha-blocker , differ from chlorthalidone , a diuretic , with respect to coronary heart disease ( CHD ) and other cardiovascular disease ( CVD ) events in hypertensive patients at high risk of CHD . In February 2000 , the doxazosin treatment arm was discontinued , and findings through December 1999 were reported . This report includes an additional 9232 participant-years and 939 CVD events . At 623 clinical centers , patients ( aged > or=55 years ) with hypertension and at least 1 other CHD risk factor were r and omly assigned to either chlorthalidone or doxazosin . The primary outcome measure was the combined occurrence of fatal CHD or nonfatal myocardial infa rct ion ( MI ) , analyzed by intent to treat ; prespecified secondary outcome measures included all-cause mortality , stroke , combined CHD ( fatal CHD , nonfatal MI , hospitalized angina , and coronary revascularization ) , and combined CVD ( combined CHD , stroke , angina treated outside the hospital , heart failure , and peripheral arterial disease ) . Mean follow-up was 3.2 years . There was no difference in primary outcome between the arms ( relative risk [ RR ] , 1.02 ; 95 % confidence interval [ CI ] , 0.92 to 1.15 ) . All-cause mortality also did not differ ( RR , 1.03 ; 95 % CI , 0.94 to 1.13 ) . However , the doxazosin arm compared with the chlorthalidone arm had a higher risk of stroke ( RR , 1.26 ; 95 % CI , 1.10 to 1.46 ) and combined CVD ( RR 1.20 ; 95 % CI , 1.13 to 1.27 ) . These findings confirm the superiority of diuretic-based over alpha-blocker-based antihypertensive treatment for the prevention of CVD Rationale : The evidence regarding the potential health benefits of nut consumption among individuals with type 2 diabetes mellitus is limited . Objective : To examine intake of total and specific types of nuts , including tree nuts and peanuts , in relation to subsequent risk of cardiovascular disease ( CVD ) , including coronary heart disease and stroke , and all-cause and cause-specific mortality among individuals with diabetes mellitus . Methods and Results : This prospect i ve analysis included 16 217 men and women with diabetes mellitus at baseline or diagnosed during follow-up ( Nurses ’ Health Study : 1980–2014 , Health Professionals Follow-Up Study : 1986–2014 ) .  Nut consumption was assessed using a vali date d food frequency question naire and up date d every 2 to 4 years . During 223 682 and 254 923 person-years of follow-up , there were 3336 incident CVD cases and 5682 deaths , respectively . Higher total nut consumption was associated with a lower risk of CVD incidence and mortality . The multivariate-adjusted hazard ratios ( 95 % CIs ) for participants who consumed 5 or more servings of total nuts per week ( 1 serving=28 g ) , compared with those who consumed < 1 serving per month , were 0.83 ( 0.71–0.98 ; P trend=0.01 ) for total CVD incidence , 0.80 ( 0.67–0.96 ; P trend=0.005 ) for coronary heart disease incidence , 0.66 ( 0.52–0.84 ; P trend < 0.001 ) for CVD mortality , and 0.69 ( 0.61–0.77 ; P trend < 0.001 ) for all-cause mortality .  Total nut consumption was not significantly associated with risk of stroke incidence or cancer mortality . For specific types of nuts , higher tree nut consumption was associated with lower risk of total CVD , coronary heart disease incidence , and mortality because of CVD , cancer , and all causes , whereas peanut consumption was associated with lower all-cause mortality only ( all P trend < 0.001 ) . In addition , compared with participants who did not change the consumption of total nuts from pre- to post-diabetes mellitus diagnosis , participants who increased consumption of total nuts after diabetes mellitus diagnosis had an 11 % lower risk of CVD , a 15 % lower coronary heart disease risk , a 25 % lower CVD mortality , and a 27 % lower all-cause mortality . The associations persisted in subgroup analyses stratified by sex/cohort , body mass index at diabetes mellitus diagnosis , smoking status , diabetes mellitus duration , nut consumption before diabetes mellitus diagnosis , or diet quality . Conclusions : Higher consumption of nuts , especially tree nuts , is associated with lower CVD incidence and mortality among participants with diabetes mellitus . These data provide novel evidence that supports the recommendation of incorporating nuts into healthy dietary patterns for the prevention of CVD complications and premature deaths among individuals with diabetes mellitus 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 ) OBJECTIVE To examine the relation of  white blood cell ( WBC ) count to the development of cardiovascular disease ( CVD ) , including coronary heart disease , stroke , peripheral arterial disease , and cardiac failure . Traditional CVD risk factors , hematocrit , and vital capacity were considered . DESIGN Prospect i ve cohort analysis with one baseline examination of relevant risk factors and 12 years of follow-up for CVD . PARTICIPANTS AND METHODS A community-based sample ( Farmingham Offspring Study ) of 1393 men and 1401 women who were free of CVD at the onset of the study and who were between the ages of 30 and 59 years at baseline .  Time-dependent multiple variable logistic regression methods were used . RESULTS There were 180 CVD events in men and 80 in women . The WBC count was correlated most strongly with the number of cigarettes smoked per day , hematocrit , and vital capacity . Among nonsmoking men with WBC counts within the normal range , the age-adjusted WBC count was significantly associated with CVD and coronary heart disease incidence . For each 1.0 x 10(9)/L-cell difference in WBC count , the CVD risk increased 32 % . In women , each 1.0 x 10(9)/L-cell increment in WBC count was associated with a 17 % increase in CVD risk , but only in smokers , and the relationship was not statistically significant after adjustment for relevant risk factors . CONCLUSIONS The degree of elevation of WBC count within the normal range is a marker for increased risk of CVD that is partially explained by cigarette smoking . Future studies should include differential WBC determinations to assess their association with CVD 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 BACKGROUND Heart rate variability ( HRV ) , a noninvasive measure of autonomic dysfunction and a risk factor for cardiovascular disease ( CVD ) , has not been systematic ally studied in nondialysis chronic kidney disease ( CKD ) . METHODS HRV was assessed using 24-h Holter monitoring in 305 subjects from the Renal Research Institute-CKD Study , a four-center prospect i ve cohort of CKD ( Stages 3 - 5 ) .  Multiple linear regression was used to assess predictors of HRV ( both time and frequency domain ) and Cox regression used to predict outcomes of CVD , composite of CVD/death and end-stage renal disease ( ESRD ) . RESULTS A total of 47 CVD , 67 ESRD and 24 death events occurred over a median follow-up of 2.7 years . Lower HRV was significantly associated with older age , female gender , diabetes , higher heart rate , C-reactive protein and phosphorus , lower serum albumin and Stage 5 CKD . Lower HRV ( mostly frequency domain ) was significantly associated with higher risk of CVD and the composite end point of CVD or death . Significantly , lower HRV ( frequency domain ) was associated with higher risk of progression to ESRD , although this effect was relatively weaker . CONCLUSIONS This study draws attention to the importance of HRV as a relatively under recognized predictor of adverse cardiovascular and renal outcomes in patients with nondialysis CKD . Whether interventions that improve HRV will improve these outcomes in this high-risk population deserves further study BACKGROUND Although basic research suggests that vitamins may have an important role in the prevention of cardiovascular diseases ( CVD ) , the data from cohort studies and clinical trials are inconclusive . METHODS This prospect i ve cohort study was conducted among 83 639 male physicians residing in the United States who had no history of CVD or cancer . At baseline , data on use of vitamin E , ascorbic acid ( vitamin C ) , and multivitamin supplements were provided by a self-administered question naire . Mortality from CVD and coronary heart disease ( CHD ) was assessed by death certificate review . RESULTS Use of supplements was reported by 29 % of the participants . During a mean follow-up of 5.5 years , 1037 CVD deaths occurred , including 608 CHD deaths . After adjustment for several cardiovascular risk factors , supplement use was not significantly associated with total CVD or CHD mortality . For vitamin E use , the relative risks ( RRs ) were 0.92 ( 95 % confidence interval [ CI ] , 0.70 - 1.21 ) for total CVD mortality and 0.88 ( 95 % CI , 0.61 - 1.27 ) for CHD mortality ; for use of vitamin C , the RRs were 0.88 ( 95 % CI , 0.70 - 1.12 ) for total CVD mortality and 0.86 ( 95 % CI , 0.63 - 1.18 ) for CHD mortality ; and for use of multivitamin supplements , the RRs were 1.07 ( 95 % CI , 0.91 - 1.25 ) for total CVD mortality and 1.02 ( 95 % CI , 0.83 - 1.25 ) for CHD mortality . CONCLUSIONS In this large cohort of apparently healthy US male physicians , self-selected supplementation with vitamin E , vitamin C , or multivitamins was not associated with a significant decrease in total CVD or CHD mortality . Data from ongoing large r and omized trials will be necessary to definitely establish small potential benefits of vitamin supplements on subsequent cardiovascular risk 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 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 Objectives To examine associations between sarcopenia , obesity , and sarcopenic obesity and risk of cardiovascular disease ( CVD ) and all-cause mortality in older men . Design Prospect i ve cohort study . Setting British Regional Heart Study . Participants Men aged 60–79 years ( n = 4,252 ) . Measurements Baseline waist circumference ( WC ) and midarm muscle circumference ( MAMC ) measurements  were used to classify participants into four groups : sarcopenic , obese , sarcopenic obese , or optimal WC and MAMC . The cohort was followed for a mean of 11.3 years for CVD and all-cause mortality . Cox regression analyses assessed associations between sarcopenic obesity groups and all-cause mortality , CVD mortality , CVD events , and coronary heart disease ( CHD ) events . Results There were 1,314 deaths , 518 CVD deaths , 852 CVD events , and 458 CHD events during follow-up . All-cause mortality risk was significantly greater in sarcopenic ( HR = 1.41 , 95 % CI = 1.22–1.63 ) and obese ( HR = 1.21 , 95 % CI = 1.03–1.42 ) men than in the optimal reference group , with the highest risk in sarcopenic obese ( HR = 1.72 , 95 % CI = 1.35–2.18 ) , after adjustment for lifestyle characteristics . Risk of CVD mortality was significantly greater in sarcopenic and obese but not sarcopenic obese men . No association was seen between sarcopenic obesity groups and CHD or CVD events . Conclusion Sarcopenia and central adiposity were associated with greater cardiovascular mortality and all-cause mortality . Sarcopenic obese men had the highest risk of all-cause mortality but not CVD mortality . Efforts to promote healthy aging should focus on preventing obesity and maintaining muscle mass Background —Cardiovascular disease ( CVD ) is the leading cause of mortality in men and women in the United States , yet prior research has shown a lack of awareness of risk among women . The purpose of this study was to assess the contemporary awareness , knowledge , and perceptions related to CVD risk among American women and to evaluate trends since 1997 , when the American Heart Association initiated a national campaign to improve awareness of CVD among women . Methods and Results —A telephone survey of a nationally representative r and om sample of women was conducted in June and July 2003 , with an oversampling of black and Hispanic women ; results were compared with those of similar surveys in 2000 and 1997 . The present survey included 1024 respondents age ≥25 years ; 68 % were white , 12 % black , 12 % Hispanic , and 8 % other ethnicities .  Awareness , knowledge , and perceptions about heart disease were evaluated by use of a st and ard interviewer-assisted question naire . A shift in awareness of heart disease as the leading killer of women has occurred since 1997 . In 2003 , 46 % of respondents spontaneously identified heart disease as the leading cause of death in women , up from 30 % in 1997 ( P < 0.05 ) and 34 % in 2000 ( P < 0.05 ) . In contrast , the percentage of women citing cancer as leading cause of death has significantly decreased . Black , Hispanic , and younger women ( < 45 years old ) had lower awareness of heart disease as their leading cause of death than did white and older women . Nearly all women reported comfort in discussing prevention with healthcare providers , but only 38 % of women reported that their doctors had ever discussed heart disease with them . Conclusions —Awareness of CVD has increased , although a significant gap between perceived and actual risk of CVD remains . Educational interventions to improve awareness and knowledge are needed , particularly for minority and younger women Background Cardiovascular disease ( CVD ) is a major cause of death in China . Despite government efforts , the majority of hypertensive and diabetic patients in China do not receive proper treatment . Reducing CVD events requires long-term care that is proactive , patient-centred , community-based , and sustainable . We have design ed a package of interventions for patients at high risk of CVD to be implemented by family doctors based in township hospitals ( providers of primary care ) in rural Zhejiang , China . This trial aims to determine whether the systematic CVD risk reduction package results in reduced CVD events among patients at risk of CVD compared with usual care , and whether the package is cost-effective and suitable for routine implementation and scale-up . Methods / Design This is a prospect i ve , open-label , cluster r and omized controlled trial ( RCT ) with blinded data analysis . The trial will r and omize 67 township hospitals with 31,708 participants in three counties in Zhejiang Province . Participants will be identified from existing health records and will comprise adults aged 50 to 74 years , with a calculated 10-year CVD risk of 20 % or higher , or diabetes . In the intervention arm , participants will receive a package of interventions including : 1 ) healthy lifestyle counseling ( smoking cessation , and salt , oil , and alcohol reduction ) ; 2 ) prescription of a combination of drugs ( antihypertensives , aspirin , and statin ) ; and 3 ) adherence support for drug compliance and healthy lifestyle change . In the control arm , participants will receive usual care for hypertension and diabetes management at individual clinicians ’ discretion . The primary outcome is the incidence of severe CVD events over 24 months of follow-up . All CVD events will be defined according to the World Health Organization ( WHO ) monitoring of trends and determinants in cardiovascular disease ( MONICA ) definitions , diagnosed at the county hospital or higher level , and reported by the Zhejiang surveillance system . Secondary outcomes include : mean systolic and diastolic blood pressure , blood glucose , serum total cholesterol ( TC ) , and adherence to appointments , and drugs and lifestyle changes . Discussion This trial focuses on risk reduction of CVD rather than specific diseases . It is not design ed to compare therapeutic and healthy lifestyle interventions , but rather their combined effects in primary care setting s. Through the trial , we intend to underst and the effectiveness of the comprehensive CVD reduction package in routine practice . We also intend to underst and the barriers and facilitators to implementing the package , and thus to advise on policy and practice change . Trial registration Current Controlled Trials : IS RCT Introduction The high prevalence of cardiovascular disease ( CVD ) in the Hispanic population of the United States , together with low rates of health insurance coverage , suggest a potential cardiovascular health crisis . The objective of Project HEART ( Health Education Awareness Research Team ) was to promote behavior changes to decrease CVD risk factors in a high-risk Hispanic border population . Methods Project HEART took place from 2005 through 2008 as a r and omized community trial with a community-based participatory research framework using promotores de salud ( community health workers ) . A total of 328 participants with at least 1 CVD risk factor were selected by r and omizing 10 US Census tracts in El Paso , Texas , to either the experimental or the control group . The experimental group ( n = 192 ) was assigned to a series of 8 health classes using the Su Corazón , Su Vida curriculum . After 2 months of educational sessions , the group was followed for 2 months . The control group ( n = 136 ) was given basic educational material s at baseline , and no other intervention was used . Main outcomes of interest included changes in health behaviors and clinical measures . Results Participants in the experimental group showed more awareness of CVD risk factors , more confidence in the control of these factors , and improved dietary habits ( ie , lower salt and cholesterol intake , better weight-control practice s ) compared with the control group . Total cholesterol was 3 % lower in the experimental than in the control participants , and non – high-density lipoprotein cholesterol and low-density lipoprotein cholesterol were both 5 % lower . Conclusion The HEART trial suggests that community health education using promotores de salud is a viable strategy for CVD risk reduction in a Hispanic border community 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 Background The burden of cardiovascular diseases ( CVDs ) remains unclear in many regions of the world . Objectives The GBD ( Global Burden of Disease ) 2015 study integrated data on disease incidence , prevalence , and mortality to produce consistent , up-to- date estimates for cardiovascular burden . Methods CVD mortality was estimated from vital registration and verbal autopsy data . CVD prevalence was estimated using modeling software and data from health surveys , prospect i ve cohorts , health system administrative data , and registries . Years lived with disability ( YLD ) were estimated by multiplying prevalence by disability weights . Years of life lost ( YLL ) were estimated by multiplying age-specific CVD deaths by a reference life expectancy . A sociodemographic index ( SDI ) was created for each location based on income per capita , educational attainment , and fertility . Results In 2015 , there were an estimated 422.7 million cases of CVD ( 95 % uncertainty interval : 415.53 to 427.87 million cases ) and 17.92 million CVD deaths ( 95 % uncertainty interval : 17.59 to 18.28 million CVD deaths ) . Declines in the age-st and ardized CVD death rate occurred between 1990 and 2015 in all high-income and some middle-income countries . Ischemic heart disease was the leading cause of CVD health lost globally , as well as in each world region , followed by stroke . As SDI increased beyond 0.25 , the highest CVD mortality shifted from women to men . CVD mortality decreased sharply for both sexes in countries with an SDI > 0.75 . Conclusions CVDs remain a major cause of health loss for all regions of the world . Sociodemographic change over the past 25 years has been associated with dramatic declines in CVD in regions with very high SDI , but only a gradual decrease or no change in most regions . Future up date s of the GBD study can be used to guide policymakers who are focused on reducing the overall burden of noncommunicable disease and achieving specific global health targets for CVD 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 The Mediterranean diet was first characterized as a heart-protective diet in the 1960s . The significant cardioprotective effects of the Mediterranean diet in comparison to the st and ard-care low-fat diet have been established in the primary prevention of cardiovascular disease ( CVD ) ; however , there is insufficient evidence in secondary prevention research to influence the current st and ard of care . Opportunity exists to assess the Mediterranean diet as a therapeutic target for secondary CVD prevention within Australia 's ethnoculturally diverse communities . The AUSMED Heart Trial is a multisite r and omized controlled trial that will evaluate the efficacy of the Mediterranean diet for secondary prevention of CVD in the Australian health care setting . This trial aims to evaluate the effect of a 6-month Mediterranean diet intervention ( delivered by dietitians ) versus a " st and ard-care " low-fat diet in reducing the composite incidence of cardiovascular events at 12 months and at trial end in participants with documented evidence of a previous acute myocardial infa rct ion at trial entry . The quality of the diet at baseline and follow-up will be assessed using comprehensive dietary question naires and diaries as well as relevant dietary biomarkers ( such as urinary polyphenols and erythrocyte fatty acids ) . Cardiovascular risk markers , including novel measures of immune and inflammatory status , endothelial function , vascular compliance , platelet activity , and body composition , will be collected to explore possible mechanisms for treatment effect . Cost-effectiveness will also be estimated to support policy translation . We plan to recruit 1,032 participants ( 516 per arm ) from cardiology clinics in major Australian hospitals in Melbourne , Adelaide , and Brisbane 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 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 ( 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 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 Mainstream preventive interventions often fail to reach poor population s with a high risk of cardiovascular diseases ( CVDs ) in Pakistan . A community-based CVD primary prevention project aim ed at developing approaches to reduce risk factors in such population s was established by Heartfile in collaboration with the National Rural Support Program in the district of Lodhran . The project implemented a range of activities integrated with existing social and health service mechanisms during a three year intervention period 2000/01 - 03/04 . These were targeted in 4 key setting s : community health education , mass media interventions , training of health professionals and health education through Lady Health Workers . The project received support from the Department for International Development , UK . At the community level , a pre-test-post-test quasi-experimental design was used for examining project outcomes related to the community component of the intervention . Pre and post-intervention ( training ) evaluations were conducted involving all health care providers in r and omly selected workshops in order to determine baseline levels of knowledge and the impact of training on knowledge level . In order to assess practice s of physician and non-physician health care providers patient interviews , with control comparisons were conducted at each health care facility . Significant positive changes were observed in knowledge levels at a community level in the district of intervention compared with baseline knowledge levels particularly in relation to a heart healthy diet , beneficial level of physical activity , the causes of high blood pressure and heart attack and the effects of high blood pressure and active and passive smoking on health . Significant changes in behaviors at a practice level were not shown in the district of intervention . However the project played a critical role in spurring national action for the prevention and control of non-communicable diseases and introducing sustainable public health interventions for poor communities in Pakistan CONTEXT Hypertension is associated with a significantly increased risk of morbidity and mortality . Only diuretics and beta-blockers have been shown to reduce this risk in long-term clinical trials . Whether newer antihypertensive agents reduce the incidence of cardiovascular disease ( CVD ) is unknown . OBJECTIVE To compare the effect of doxazosin , an alpha-blocker , with chlorthalidone , a diuretic , on incidence of CVD in patients with hypertension as part of a study of 4 types of antihypertensive drugs : chlorthalidone , doxazosin , amlodipine , and lisinopril . DESIGN R and omized , double-blind , active-controlled clinical trial , the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial , initiated in February 1994 . In January 2000 , after an interim analysis , an independent data review committee recommended discontinuing the doxazosin treatment arm based on comparisons with chlorthalidone . Therefore , outcomes data presented herein reflect follow-up through December 1999 . SETTING A total of 625 centers in the United States and Canada . PARTICIPANTS A total of 24,335 patients ( aged > or = 55 years ) with hypertension and at least 1 other coronary heart disease ( CHD ) risk factor who received either doxazosin or chlorthalidone .  INTERVENTIONS Participants were r and omly assigned to receive chlorthalidone , 12.5 to 25 mg/d ( n=15,268 ) , or doxazosin , 2 to 8 mg/d ( n=9067 ) , for a planned follow-up of 4 to 8 years . MAIN OUTCOME MEASURES The primary outcome measure was fatal CHD or nonfatal myocardial infa rct ion ( MI ) , analyzed by intent to treat ; secondary outcome measures included all-cause mortality , stroke , and combined CVD ( CHD death , nonfatal MI , stroke , angina , coronary revascularization , congestive heart failure [ CHF ] , and peripheral arterial disease ) ; compared by the chlorthalidone group vs the doxazosin group . RESULTS Median follow-up was 3.3 years . A total of 365 patients in the doxazosin group and 608 in the chlorthalidone group had fatal CHD or nonfatal MI , with no difference in risk between the groups ( relative risk [ RR ] , 1.03 ; 95 % confidence interval [ CI ] , 0.90 - 1.17 ; P=.71 ) . Total mortality did not differ between the doxazosin and chlorthalidone arms ( 4-year rates , 9.62 % and 9.08 % , respectively ; RR , 1.03 ; 95 % CI , 0.90 - 1.15 ; P=.56 . ) The doxazosin arm , compared with the chlorthalidone arm , had a higher risk of stroke ( RR , 1.19 ; 95 % CI , 1.01 - 1.40 ; P=.04 ) and combined CVD ( 4-year rates , 25.45 % vs 21.76 % ; RR , 1.25 ; 95 % CI , 1.17 - 1.33 ; P<.001 ) . Considered separately , CHF risk was doubled ( 4-year rates , 8.13 % vs 4.45 % ; RR , 2.04 ; 95 % CI , 1.79 - 2.32 ; P<.001 ) ; RRs for angina , coronary revascularization , and peripheral arterial disease were 1.16 ( P<.001 ) , 1.15 ( P=.05 ) , and 1.07 ( P=.50 ) , respectively . CONCLUSION Our data indicate that compared with doxazosin , chlorthalidone yields essentially equal risk of CHD death/nonfatal MI but significantly reduces the risk of combined CVD events , particularly CHF , in high-risk hypertensive patients BACKGROUND Whether consumption of potatoes , which are rich in potassium and have a high glycemic index and glycemic load , is associated with the risk of cardiovascular disease ( CVD ) is unknown . OBJECTIVE The aim was to examine the association between potato consumption and risk of total and specific CVD events as well as mortality from CVD in 2 prospect i ve cohorts of Swedish adults , a population with a high consumption of potatoes .  DESIGN Information on potato consumption was available from 69,313 men and women , free of CVD and diabetes , in the Cohort of Swedish Men and the Swedish Mammography Cohort .  Nonfatal and fatal cases of CVD diagnosed over 13 y of follow-up were identified by linkage with the Swedish National Patient and Cause of Death Registers . Analyses were conducted by using a Cox proportional hazards regression model , controlled for potential confounders . RESULTS We ascertained 10,147 major CVD events [ myocardial infa rct ion ( MI ) , heart failure ( HF ) , and stroke ] and 4003 deaths due to CVD . Total potato consumption was not associated with the risk of major CVD events , specific CVD endpoints , or CVD mortality in either men or women . Multivariable HRs ( 95 % CIs ) per an increment of 3 servings/wk of total potato consumption ( boiled potatoes , fried potatoes , and French fries ) were 1.00 ( 0.97 , 1.02 ) for major CVD events , 1.01 ( 0.97 , 1.04 ) for MI , 0.97 ( 0.93 , 1.02 ) for HF , 1.01 ( 0.97 , 1.05 ) for stroke , and 0.99 ( 0.95 , 1.03 ) for CVD mortality . There were no significant trends between the consumption of boiled potatoes , fried potatoes , or French fries and risk of any CVD outcome . CONCLUSION Potato consumption was not associated with the risk of CVD  in this population . The Swedish Mammography Cohort and the Cohort of Swedish Men are registered at clinical trials.gov as NCT01127698 and NCT01127711 , respectively Context Long-term outcomes of patients with a reduced glomerular filtration rate ( GFR ) who are treated for hypertension are not well-known . Contribution This analysis of a large multicenter trial found that coronary heart disease ( CHD ) was much more common than end-stage renal disease ( 15 % vs. 6 % ) in hypertensive patients with moderate to severe reductions in GFR who were followed for 6 years . Lower baseline GFR was associated with higher risk for CHD independent of other risk factors . Neither amlodipine nor lisinopril is superior to chlorthalidone in preventing CHD , stroke , or combined CVD , and chlorthalidone is superior to both for preventing heart failure , independent of level of renal function . Caution s These are post hoc subgroup findings , and proteinuria was not measured . The Editors It is estimated that more than 10 million Americans have chronic kidney disease ( 1 , 2 ) . The prevalence of chronic kidney disease is particularly high in older adults ; it is estimated to be greater than 25 % in persons older than 70 years of age . Patients with chronic kidney disease are at very high risk for cardiovascular disease ( CVD ) ( 3 - 8 ) . However , the long-term outcomes of older patients who have a mild or moderate reduction in glomerular filtration rate ( GFR )  , particularly with regard to CVD , are not well-known . Because of the large population of older adults with chronic kidney disease , it is important , from a public health and a clinical st and point , to quantify and underst and the comparative risks for CVD and renal disease in these patients . Management of hypertension is an important aspect of management in patients with chronic kidney disease ; in patients with proteinuria , drugs that inhibit the reninangiotensin axis have been shown to be superior to conventional antihypertensive drug therapy for preservation of renal function ( 1 , 9 , 10 ) . However , it is uncertain whether the choice of antihypertensive drug therapy affects risk for CVD in patients with chronic kidney disease ( 11 , 12 ) . The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial ( ALLHAT ) is a large clinical trial design ed to compare the efficacy of treatment with different first-line antihypertensive agents on CVD outcomes in high-risk patients with hypertension who are older than 55 years of age ( 13 - 15 ) . The objectives of this report from the ALLHAT data are to 1 ) compare rates of cardiovascular events with rates of development of end-stage renal disease ( ESRD ) in high-risk older adults with hypertension who have reduced GFR ; 2 ) determine whether reduced GFR is independently associated with an increased risk for CVD after adjusting for traditional cardiovascular risk factors ; and 3 ) report the efficacy of first-step treatment with a calcium-channel blocker ( amlodipine ) or an angiotensin-converting enzyme ( ACE ) inhibitor ( lisinopril ) , each compared with a diuretic ( chlorthalidone ) , in modifying CVD outcomes in high-risk patients with hypertension who are stratified by baseline GFR . Methods The rationale and design of ALLHAT have been presented in detail elsewhere ( 13 ) . The study received institutional review board approval , and participants provided written informed consent . Participants were men and women 55 years of age or older who had hypertension with at least 1 additional risk factor for coronary heart disease ( CHD ) . The risk factors included previous ( > 6 months ) myocardial infa rct ion ( MI ) or stroke , left ventricular hypertrophy demonstrated by electrocardiography or echocardiography , history of type 2 diabetes , current cigarette smoking , high-density lipoprotein cholesterol level of less than 0.91 mmol/L ( < 35 mg/dL ) , and documentation of other atherosclerotic CVD . Exclusion criteria included a history of symptomatic heart failure and /or a known left ventricular ejection fraction of less than 0.35 and a serum creatinine level greater than 176.8 mol/L ( > 2 mg/dL ) as reported by the investigator . Participants ( n= 33 357 ) were recruited at 623 centers in the United States , Canada , Puerto Rico , and the U.S. Virgin Isl and s between February 1994 and January 1998 ( Appendix Figure 1 ) . Appendix Figure 1 . R and omization and follow-up of participants in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial ( ALLHAT ) by treatment group . Block r and omization was stratified by center . Participants were r and omly assigned in a double-blind manner and in a 1.7:1:1 ratio to chlorthalidone , amlodipine , or lisinopril . A fourth arm of the study using the -blocker doxazosin was stopped early and is not considered in this report ( 16 ) . The goal blood pressure in each r and omly assigned group was less than 140/90 mm Hg , to be achieved by titrating the assigned study drug ( step 1 ) and by adding study -supplied , open-label agents ( atenolol , clonidine , or reserpine [ step 2 ] or hydralazine [ step 3 ] ) when necessary , at the physician 's discretion ( 16 , 17 ) . Nonpharmacologic lifestyle approaches to treatment of hypertension were recommended according to national guidelines . Other drugs , including low doses of open-label step 1 drug classes , were permitted if clinical ly indicated . Follow-up visits were at 1 month ; 3 , 6 , 9 , and 12 months ; and every 4 months thereafter . Levels of serum creatinine were measured in a single central laboratory using VITROS ( Ortho Clinical Diagnostics , Rochester , New York ) , which had a coefficient of variation of approximately 2 % . Creatinine measurements were calibrated to the Modification of Diet in Renal Disease ( MDRD ) laboratory , and no additional correction was found to be necessary ( 18 ) . A total of 1460 participants ( 4.4 % ) were missing creatinine values , and thus estimated GFR , at baseline . The simplified MDRD Study equation was used to estimate GFR ( mL/min per 1.73 m2 ) according to the following formula : 186.3 ( serum creatinine in mg/dL 1.154 ) ( age in years 0.203 ) 1.212 ( if black ) 0.742 ( if female ) ( 19 ) . Patients were classified into 3 baseline categories of GFR consistent with recommendations in the National Kidney Foundation Kidney Disease Outcomes Quality Initiative Clinical Practice Guidelines on Chronic Kidney Disease : normal or increased ( 90 mL/min per 1.73 m2 ) , mild reduction ( 60 to 89 mL/min per 1.73 m2 ) , and moderate or severe reduction ( < 60 mL/min per 1.73 m2 ) ( 1 ) . Because a serum creatinine level of greater than 176.8 mol/L ( > 2 mg/dL ) was an exclusion criterion , the percentage of patients with severe chronic kidney disease ( estimated GFR 29 mL/min per 1.73 m2 ) at baseline was very small ( 0.6 % ) . Therefore , as in another study ( 6 ) , these participants were considered along with those with moderate chronic kidney disease ( GFR 30 to 59 mL/min per 1.73 m2 ) . Patients were also classified as diabetic or not diabetic by baseline history of diabetes . The primary outcome was fatal CHD or nonfatal MI . Combined CVD was defined as a composite of the primary outcome , coronary revascularization , hospitalized angina , stroke , other treated angina , heart failure ( fatal , hospitalized , or treated nonhospitalized ) , and peripheral arterial disease . Coronary revascularization included coronary artery bypass grafting , percutaneous angioplasty , insertion of stents , and atherectomy . Peripheral vascular disease included intermittent claudication or arterial disease of the lower extremities leading to procedures , such as revascularizations , angioplasty of peripheral arteries , or amputation . End-stage renal disease included death from kidney disease , kidney transplantation , and start of long-term kidney dialysis . Study outcomes were defined in the ALLHAT Manual of Operations ( available from the authors on request ) , were assessed by site investigators at follow-up visits , and were reported to the Clinical Trials Center . Medical review ers from the Clinical Trials Center review ed all events for concordance with study criteria . More detailed information was collected on a r and om ( 10 % ) subset of CHD and stroke events and was review ed by the Endpoints Subcommittee to vali date the procedure of using physician diagnoses . Statistical Analyses Data were analyzed according to the participants ' r and omly assigned treatments regardless of their subsequent medications ( intention-to-treat analysis ) . Baseline characteristics were compared across treatments and the 3 GFR groups by using the Z-test for continuous covariates and contingency table analyses for categorical data . Cox proportional hazards models were used to obtain hazard ratios and 95 % CIs for time to CHD , combined CVD , and stroke to assess the effects of treatment within each of the 3 GFR strata . Because baseline characteristics are similar across treatment groups , no adjustment was deemed necessary . Additional models were used to assess the impact of baseline GFR ( using deciles ) on CHD and combined CVD . Baseline characteristics are not expected to be similar across the various GFR groups defined by deciles ; therefore , adjustments are necessary . Cox test assumptions were examined using loglog plots and tests of treatment by time ( time-dependent ) interaction terms . Because the assumptions were violated in the case of heart failure , logistic models were used to estimate odds ratios for this end point . The consistency of treatment effects across subgroups was examined in the Cox and logistic models by calculating the differences in the log likelihood for models with and without the interaction terms . Treatment effects by GFR subgroup were also analyzed for participants with a history of diabetes by using the aforementioned methods . A P value less than 0.05 indicated statistical significance for the results . Role of the Funding Sources This study was supported by contract NO1-HC-35130 from the National Heart , Lung , and Blood Institute ( NHLBI ) ; the NHLBI was involved in the collection , analysis , and interpretation of the data and the decision to su bmi t the manuscript for publication but was not involved in the direct operations of the study centers . Study medications were supplied by
68 % of the outcomes reported showed that clinical pharmacy services were associated with better improvement in patients ' outcomes compared with the control group .
The involvement of a pharmacist demonstrated an ability to improve CVD outcomes through providing educational intervention , medicine management intervention , or a combination of both .
These interventions result ed in improved CVD risk factors , improved patient outcomes , and reduced number of drug-related problems with a direct effect on CVD control .
These improvements may lead to an improvement in patient quality of life , better use of health care re sources , and a reduced rate of mortality
BACKGROUND Cardiovascular disease ( CVD ) is considered to be the main cause of death and one of the most common diseases affecting health care systems worldwide .
Many methods have been used to improve CVD outcomes , one of which is to involve clinical pharmacists in the direct care of patients with CVD .
OBJECTIVE To perform a systematic review assessing the effectiveness of clinical pharmacist interventions within a multidisciplinary team in the secondary prevention of CVD , using studies conducted on patients with heart failure , coronary heart disease , or those with CVD risk factors .