Development of a set of mobile phone text messages designed for prevention of recurrent cardiovascular events IMProving Adherence using Combination Therapy (IMPACT): design and protocol of a randomised controlled trial in primary care. Design and rationale of the tobacco, exercise and diet messages (TEXT ME) trial of a text message-based intervention for ongoing prevention of cardiovascular disease in people with coronary disease: a randomised controlled trial protocol Leisure time physical activity and long-term cardiovascular and cancer outcomes: the Busselton Health Study Mediterranean diet and the incidence of cardiovascular disease: a Spanish cohort. A cardiovascular disease policy model that predicts life expectancy taking into account socioeconomic deprivation HEART: heart exercise and remote technologies: A randomized controlled trial study protocol The effects of Hartcoach, a life style intervention provided by telephone on the reduction of coronary risk factors: a randomised trial Lipoprotein(a) as a cardiovascular risk factor: current status Polypill for the prevention of cardiovascular disease (PolyIran): study design and rationale for a pragmatic cluster randomized controlled trial Prospective association of the Mediterranean diet with cardiovascular disease incidence and mortality and its population impact in a non-Mediterranean population: the EPIC-Norfolk study Cardiovascular disease risk reduction in rural China: a clustered randomized controlled trial in Zhejiang Dietary patterns and mortality from cardiovascular disease: Isfahan Cohort Study Reducing salt intake for prevention of cardiovascular diseases in high-risk patients by advanced health education intervention (RESIP-CVD study), Northern Thailand: study protocol for a cluster randomized trial Cardiovascular Outcomes in Action to Control Cardiovascular Risk in Diabetes: Impact of Blood Pressure Level and Presence of Kidney Disease Cardiovascular risk profile and outcome of patients with abdominal aortic aneurysm in out-patients with atherothrombosis: data from the Reduction of Atherothrombosis for Continued Health (REACH) Registry. World Salt Awareness Week. Statins for Primary Prevention: The Debate Is Intense, but the Data Are Weak. Higher Dietary Calcium Intakes Are Associated With Reduced Risks of Fractures, Cardiovascular Events, and Mortality: A Prospective Cohort Study of Older Men and Women. A randomised controlled trial of a consumer-focused e-health strategy for cardiovascular risk management in primary care: the Consumer Navigation of Electronic Cardiovascular Tools (CONNECT) study protocol Evaluating the use of mobile phone technology to enhance cardiovascular disease screening by community health workers Use of a Multidrug Pill In Reducing cardiovascular Events (UMPIRE): rationale and design of a randomised controlled trial of a cardiovascular preventive polypill-based strategy in India and Europe Study design of ASPirin in Reducing Events in the Elderly (ASPREE): a randomized, controlled trial. Which Patients Does the SPRINT Study Not Apply To and What Are the Appropriate Blood Pressure Goals in These Populations? Using mobile technology to support lower-salt food choices for people with cardiovascular disease: protocol for the SaltSwitch randomized controlled trial [Evaluation of the efficacy of a comprehensive programme of secondary prevention of cardiovascular disease in primary care: the PREseAP Study]. National Study of Physician Awareness and Adherence to Cardiovascular Disease Prevention Guidelines Effectiveness of blood pressure-lowering drug treatment by levels of absolute risk: post hoc analysis of the Australian National Blood Pressure Study Ten-year legacy effects of baseline blood pressure ‘treatment naivety’ in the Second Australian National Blood Pressure study Efficacy of a nurse-led email reminder program for cardiovascular prevention risk reduction in hypertensive patients: a randomized controlled trial. Pneumococcal infection and immunologic response to pneumococcal vaccine in chronic obstructive pulmonary disease. A pilot study. Predictive ability of the SCORE Belgium risk chart for cardiovascular mortality. Coronary artery calcification compared with carotid intima-media thickness in the prediction of cardiovascular disease incidence: the Multi-Ethnic Study of Atherosclerosis (MESA). Pilot Testing of the PRAISEDD Intervention Among African American and Low-Income Older Adults A tailored lifestyle intervention to reduce the cardiovascular disease risk of individuals with Familial Hypercholesterolemia (FH): design of the PRO-FIT randomised controlled trial The Impact of Health Behaviours on Incident Cardiovascular Disease in Europeans and South Asians – A Prospective Analysis in the UK SABRE Study Texting and Mobile Phone App Interventions for Improving Adherence to Preventive Behavior in Adolescents: A Systematic Review A population-based lifestyle intervention to promote healthy weight and physical activity in people with cardiac disease: The PANACHE (Physical Activity, Nutrition And Cardiac HEalth) study protocol A score for the prediction of cardiovascular events in the hypertensive aged. 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). A multifaceted strategy using mobile technology to assist rural primary healthcare doctors and frontline health workers in cardiovascular disease risk management: protocol for the SMARTHealth India cluster randomised controlled trial Dietary fried fish intake increases risk of CVD: the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Association between sauna bathing and fatal cardiovascular and all-cause mortality events. Blood Pressure and Risk of Secondary Cardiovascular Events in Women: The Women’s Antioxidant Cardiovascular Study (WACS) An economic case for a cardiovascular polypill? A cost analysis of the Kanyini GAP trial. High Diet Quality Is Associated with a Lower Risk of Cardiovascular Disease and All-Cause Mortality in Older Men123 E-Rehabilitation – an Internet and mobile phone based tailored intervention to enhance self-management of Cardiovascular Disease: study protocol for a randomized controlled trial Look AHEAD (Action for Health in Diabetes): design and methods for a clinical trial of weight loss for the prevention of cardiovascular disease in type 2 diabetes.
Background : Supporting lifestyle change is an effective way of preventing recurrent events in people with cardiovascular disease ( CVD ) . However , there is a need to develop innovative strategies that increase access to programmes for individuals at high risk of CVD . This study aim ed to develop a bank of text messages design ed to provide advice , motivation , and support for decreasing cardiovascular risk . Design : Iterative development process with mixed methods Methods : An initial bank of 120 text messages was drafted based on behaviour change techniques , guidelines , and input from clinicians and public health experts . A question naire was then administered to participants ( n = 53 ) for evaluation of message content , usefulness , and language . To test the process of delivery , a pilot study was conducted using a specifically design ed computer programme that delivered messages to multiple mobile phones according to a pre-specified schedule . Data were collected regarding message timing , delivery , and usefulness . Results : In the qualitative question naire , 92 % of participants found the messages easy to underst and and 86 % found the messages contained useful information . Positive feedback was also obtained from the pilot study . Based on these results , together with suggestions provided , several messages were reworded and an additional 44 were written . The need for semi-personalization was also identified and a r and om set of 103 individualized messages was created . Conclusions : A final bank of 137 mobile telephone text messages design ed to support behaviour change and decrease cardiovascular risk have been developed through a multistep iterative process . This provides a scientific approach for future developers of health-related text messages BACKGROUND Cardiovascular disease ( CVD ) is the leading cause of death , and principal reason for the large difference in life expectancy between indigenous Māori and the non-indigenous population in New Zeal and . CVD guidelines recommend that people who are at high risk or who have had previous CVD should be offered aspirin , blood pressure lowering and lipid lowering therapies . However , prescribing and adherence rates are low and CVD events remain high . AIM To assess whether a medication strategy using a fixed dose combination pill ( ' polypill ' ) could improve prescribing and adherence to recommended medications , lower blood pressure and improve lipids compared with current care over 12 months . METHODS IMProving Adherence using Combination Therapy ( IMPACT ) is an open-label r and omised controlled trial comparing a once-daily polypill containing four preventive medications with usual care .  Six hundred participants who have had previous CVD events or are at high risk of CVD will be enrolled , including 300 Māori . Participants are identified , enrolled and prescribed either the polypill or current medications at their usual primary health care practice , with medications ( including the polypill ) dispensed through local community pharmacies . The polypill contains 75 mg aspirin , 40 mg simvastatin , 10 mg lisinopril and either 12.5 mg hydrochlorothiazide or 50 mg atenolol . Primary outcomes are adherence to guidelines -recommended medications and changes in systolic blood pressure and low density lipoprotein at 12 months . Secondary outcomes include other lipids , medication dispensing , barriers to adherence , CVD and other serious adverse events , quality of life and prescriber acceptability . The trial is registered with the Australian New Zeal and Clinical Trial Registry ( ACTRN12606000067572 ) Background Although supporting lifestyle change is an effective way of preventing further events in people with cardiovascular disease , providing access to such interventions is a major challenge . This study aims to investigate whether simple reminders about behaviour change sent via mobile phone text message decrease cardiovascular risk . Methods and analysis R and omised controlled trial with 6 months of follow-up to evaluate the feasibility , acceptability and effect on cardiovascular risk of repeated lifestyle reminders sent via mobile phone text messages compared to usual care .  A total of 720 patients with coronary artery disease will be r and omised to either st and ard care or the TEXT ME intervention . The intervention group will receive multiple weekly text messages that provide information , motivation , support to quit smoking ( if relevant ) and recommendations for healthy diets and exercise . The primary end point is a change in plasma low-density lipoprotein cholesterol at 6 months . Secondary end points include a change in systolic blood pressure , smoking status , quality of life , medication adherence , waist circumference , physical activity levels , nutritional status and mood at 6 months . Process outcomes related to acceptability and feasibility of TEXT ME will also be collected . Ethics and dissemination Primary ethics approval was received from Western Sydney Local Health Network Human Research Ethics Committee — Westmead . Results will be disseminated via the usual scientific forums including peer- review ed publications and presentations at international conferences . Clinical trials registration number ACTRN12611000161921 Abstract The study aim ed to investigate whether meeting leisure time physical activity recommendations was associated with reduced incident and fatal cancer or cardiovascular disease ( CVD )  in a community-based cohort of middle- to late-aged adults with long-term follow-up . At baseline , 2,320 individuals were assessed on a large number of lifestyle and clinical parameters including their level of physical activity  per week , other risk factors ( e.g. smoking and alcohol use ) various anthropometric measures , blood tests and medical history . Individuals were linked to hospital and mortality registry data to identify future cancer and cardiovascular events ( fatal and non-fatal ) out to 15 years of follow-up . Cox regression analyses adjusted for relevant confounders identified a priori were used to estimate risk for all-cause , cancer-specific and CVD-specific mortality . In the full cohort an estimated 21 % decreased risk for all-cause mortality ( HR 0.79 ; 95 % CI 0.66–0.96 ) and 22 % decreased risk for fatal/non-fatal CVD events ( HR 0.78 ; 95 % CI 0.66–0.92 ) was associated with baseline self-reported physical activity levels of 150 min or more . After exclusion of those with chronic co-morbidities ( CVD , cancer , diabetes , chronic obstructive pulmonary disease , hypertension treatment ) at baseline , lower risk for fatal/non-fatal CVD events remained significantly associated with 150 min or more of physical activity ( HR 0.77 ; 95 % CI 0.62–0.96 ) . Results from this well established prospect i ve community-based cohort study support the role of leisure time physical activity in reducing all-cause mortality and CVD events ( fatal/nonfatal ) in the broader population studied . The data also suggest that physical activity associated reductions in risk for CVD events ( fatal/nonfatal ) were not overly impacted by prevalent key non-communicable diseases BACKGROUND AND AIM The Mediterranean diet is considered a model for healthy eating . However , prospect i ve evidence in Mediterranean countries evaluating the relationship between this dietary pattern and non-fatal cardiovascular events is scarce . The aim of the present study was to evaluate the association between the adherence to the Mediterranean diet and the incidence of fatal and non-fatal cardiovascular events among initially healthy middle-aged adults from the Mediterranean area . METHODS AND RESULTS We followed-up 13,609 participants ( 60 percent women , mean age : 38 years ) initially free of cardiovascular disease ( CVD ) during 4.9 years . Participants were part of a prospect i ve cohort study of university graduates from all regions of Spain .  Baseline diet  was assessed using a vali date d 136-item food-frequency question naire . A 9-point score was used to appraise adherence to the Mediterranean diet . Incident clinical events were confirmed by a review of medical records . We observed 100 incident cases of CVD . In multivariate analyses , participants with the highest adherence to the Mediterranean diet ( score>6 ) exhibited a lower cardiovascular risk ( hazard ratio=0.41 , 95 % confidence interval [ CI ] : 0.18 - 0.95 ) compared to those with the lowest score ( <3 ) . For each 2-point increment in the score , the adjusted hazard ratios were 0.80 ( 95 % CI : 0.62 - 1.02 ) for total CVD and 0.74 ( 0.55 - 0.99 ) for coronary heart disease . CONCLUSIONS There is an inverse association between adherence to the Mediterranean diet and the incidence of fatal and non-fatal CVD in initially healthy middle-aged adults 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 Cardiovascular disease ( CVD ) is the leading cause of death worldwide . Cardiac rehabilitation ( CR ) is aim ed at improving health behaviors to slow or reverse the progression of CVD disease . Exercise is a central element of CR . Technologies such as mobile phones and the Internet ( mHealth ) offer potential to overcome many of the psychological , physical , and geographical barriers that have been associated with lack of participation in exercise-based CR . We aim to trial the effectiveness of a mobile phone delivered exercise-based CR program to increase exercise capacity and functional outcomes compared with usual CR care in adults with CVD . This paper outlines the rationale and methods of the trial . Methods A single-blinded parallel two-arm r and omized controlled trial is being conducted . A total of 170 people will be r and omized at 1:1 ratio either to receive a  mHealth CR program  or usual care .  Participants are identified by CR nurses from two metropolitan hospitals in Auckl and , New Zeal and through outpatient clinics and existing data bases . Consenting participants are contacted to attend a baseline assessment . The intervention consists of a theory-based , personalized , automated package of text and video message components via participants ' mobile phones and the Internet to increase exercise behavior , delivered over six months . The control group will continue with usual CR . Data collection occurs at baseline and 24 weeks ( post-intervention ) . The primary outcome is change in maximal oxygen uptake from baseline to 24 weeks . Secondary outcomes include post-intervention measures on self-reported physical activity ( IPAQ ) , cardiovascular risk factors ( systolic blood pressure , weight , and waist to hip ratio ) , health related quality of life ( SF-36 ) , and cost-effectiveness . Discussion This manuscript presents the protocol for a r and omized controlled trial of a mHealth exercise-based CR program . Results of this trial will provide much needed information about physical and psychological well-being , and cost-effectiveness of an automated telecommunication intervention . If effective , this intervention has enormous potential to improve the delivery of CR and could easily be scaled up to be delivered nationally ( and internationally ) in a very short time , enhancing the translational aspect of this research . It also has potential to extend to comprehensive CR ( nutrition advice , smoking cessation , medication adherence).Trial Registration Background Cardiovascular disease ( CVD ) is the leading cause of death worldwide . Secondary prevention is essential , but participation rates for cardiac rehabilitation are low . Furthermore , current programmes do not accomplish that patients with CVD change their lifestyle in a way that their individual risk factors for recurrent events decrease , therefore more effective interventions are needed . In this study , the effectiveness of the Hartcoach-programme , a telephonic secondary prevention program focussing on self management , is studied . Methods / design A multicenter , r and omised parallel-group study is being conducted . Participants are 400 patients with acute myocardial infa rct ion ( STEMI , NSTEMI , ) and patients with chronic or unstable angina pectoris ( IAP ) . Patients are recruited through the participating hospitals and r and omly assigned to the experimental group ( Hartcoach-programme plus usual care ) or the control group ( usual care).The Hartcoach-programme consists of a period of six months during which the coach contacts the patient every four to six weeks by telephone . Coaches train patients to take responsibility for the achievement and maintenance of the defined target levels for their particular individual modifiable risk factors . Target levels and treatment goals are agreed by the nurse and patient together . Data collection is blinded and occurs at baseline and after 26 weeks ( post-intervention ) . Primary outcome is change in cardiovascular risk factors ( cholesterol , body mass index , waist circumference , blood pressure , physical activity and diet ) . Secondary outcomes include chances in glucose , HbA1c , medication adherence , self-management and quality of life . Discussion This study evaluates the effects of the Hartcoach-programme on the reduction of individual risk factors of patients with CVDs . Patients who are not invited to follow a hospital based rehabilitation programme or patients who are unable to adhere to such a programme , may be reached by this home based Hartcoach-programme . If positive results are found , the implementation of the Hartcoach-programme will be extended , having implication s for the management of many people with CVD.Trial registration Aims The aims of the study were , first , to critically evaluate lipoprotein(a ) [ Lp(a ) ] as a cardiovascular risk factor and , second , to advise on screening for elevated plasma Lp(a ) , on desirable levels , and on therapeutic strategies . Methods and results The robust and specific association between elevated Lp(a ) levels and increased cardiovascular disease (CVD)/coronary heart disease ( CHD ) risk , together with recent genetic findings , indicates that elevated Lp(a ) , like elevated LDL-cholesterol , is causally related to premature CVD/CHD . The association is continuous without a threshold or dependence on LDL- or non-HDL-cholesterol levels . Mechanistically , elevated Lp(a ) levels may either induce a prothrombotic/anti-fibrinolytic effect as apolipoprotein(a ) resembles both plasminogen and plasmin but has no fibrinolytic activity , or may accelerate atherosclerosis because , like LDL , the Lp(a ) particle is cholesterol-rich , or both . We advise that Lp(a ) be measured once , using an isoform-insensitive assay , in subjects at intermediate or high CVD/CHD risk with premature CVD , familial hypercholesterolaemia , a family history of premature CVD and /or elevated Lp(a ) , recurrent CVD despite statin treatment , ≥3 % 10-year risk of fatal CVD according to European guidelines , and /or ≥10 % 10-year risk of fatal + non-fatal CHD according to US guidelines . As a secondary priority after LDL-cholesterol reduction , we recommend a desirable level for Lp(a ) < 80th percentile ( less than ∼50 mg/dL ) . Treatment should primarily be niacin 1–3 g/day , as a meta- analysis of r and omized , controlled intervention trials demonstrates reduced CVD  by niacin treatment . In extreme cases , LDL-apheresis is efficacious in removing Lp(a ) . Conclusion We recommend screening for elevated Lp(a ) in those at intermediate or high CVD/CHD risk , a desirable level < 50 mg/dL as a function of global cardiovascular risk , and use of niacin for Lp(a ) and CVD/CHD risk reduction Background The complexity of treatment regimens , costs and pill burden decrease the medication adherence and contribute to shortfall in cardiovascular preventive drug coverage . The polypill , a fixed dose combination pill of established drugs , is expected to increase adherence and reduce the costs whilst preventing major cardiovascular events ( MCVE ) . Design and methods The PolyIran trial is a pragmatic cluster r and omized trial nested within the Golestan Cohort Study ( GCS ) . Subjects were r and omized to either non-pharmacological preventive interventions alone ( minimal care arm ) or together with a polypill ( polypill arm ) comprising hydrochlorothiazide , aspirin , atorvastatin and either enalapril or valsartan . This study benefits from the infrastructure of the primary health care system in Iran and the interventions are delivered by the local auxiliary health workers ( Behvarz ) to the participants . The primary outcome of the study is the occurrence of first MCVE within five years defined as non-fatal and fatal myocardial infa rct ion , unstable angina , sudden death , heart failure , coronary artery revascularization procedures , and non-fatal and fatal stroke . Trial status From February 2011 to April 2013 , 8410 individuals ( 236 clusters ) attended the eligibility assessment . Of those , 3421 in the polypill arm and 3417 in the minimal care arm were eligible . The study is ongoing . Conclusion The infrastructure of GCS and the primary health care system in Iran enabled the conduct of this pragmatic large-scale trial . If the polypill strategy proves effective , it may be implemented to prevent cardiovascular disease in developing countries Background Despite convincing evidence in the Mediterranean region , the cardiovascular benefit of the Mediterranean diet is not well established in non-Mediterranean countries and the optimal criteria for defining adherence are unclear . The population attributable fraction ( PAF ) of adherence to this diet is also unknown . Methods In the UK-based EPIC-Norfolk prospect i ve cohort , we evaluated habitual diets assessed at baseline ( 1993–1997 ) and during follow-up ( 1998–2000 ) using food-frequency question naires  ( n = 23,902 ) . We estimated a Mediterranean diet score ( MDS ) using cut-points projected from the Mediterranean dietary pyramid , and also three other pre-existing MDSs . Using multivariable-adjusted Cox regression with repeated measures of MDS and covariates , we examined prospect i ve associations between each MDS with incident cardiovascular diseases ( CVD ) by 2009 and mortality by 2013 , and estimated PAF for each outcome attributable to low MDS . Results We observed 7606 incident CVD events ( 2818/100,000 person-years ) and 1714 CVD deaths ( 448/100,000 ) . The MDS based on the Mediterranean dietary pyramid was significantly associated with lower incidence of the cardiovascular outcomes , with hazard ratios ( 95 % confidence intervals ) of 0.95 ( 0.92–0.97 ) per one st and ard deviation for incident CVD and 0.91 ( 0.87–0.96 ) for CVD mortality . Associations were similar for composite incident ischaemic heart disease and all-cause mortality . Other pre-existing MDSs showed similar , but more modest associations . PAF due to low dietary pyramid based MDS ( < 95th percentile ) was 3.9 % ( 1.3–6.5 % ) for total incident CVD and 12.5 % ( 4.5–20.6 % ) for CVD mortality . Conclusions Greater adherence to the Mediterranean diet was associated with lower CVD incidence and mortality  in the UK . This diet has an important population health impact for the prevention of CVD 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 Background / Objectives : Evidence about the relation between dietary patterns and cardiovascular disease ( CVD ) is scarce in Middle Eastern countries . This study was performed to examine the association between major dietary patterns and  CVD mortality in Iranian adults . Subjects/ Methods : This population -based prospect i ve cohort study was conducted among 4834 r and omly selected participants aged ⩾35 years from urban and rural areas of central Iran ( 2001–2009 ) ( the Isfahan Cohort Study ) .  Dietary intakes were assessed using a food frequency question naire , and major dietary patterns were identified by means of exploratory factor analysis . Subjects or their next of kin were interviewed biannually looking for possible occurrence of events . Cardiovascular mortality was defined as fatal myocardial infa rct ion , fatal stroke and sudden cardiac death . Results : During the median follow-up of 9.0 years and 50 282 person-years , we found a total of 118 CVD mortalities . Four major dietary patterns were identified : ' Western ' , ' Mediterranean ' , ' Animal fat ' and ' Fast food ' . Adherence to the Mediterranean dietary pattern was protectively associated with CVD mortality , such that those in the highest quartile were 46 % ( hazard ratio ( HR ) : 0.54 ; 95 % confidence interval ( CI ) : 0.32–0.91 ; P-value for trend=0.03 ) less likely to have incident CVD mortality than those in the lowest quartile . Further adjustment for potential confounders strengthened this association ( HR : 0.42 ; 95 % CI : 0.19–0.96 ; P-value for trend=0.02 ) . We found no significant association between adherence to the Western , animal fat and fast food dietary patterns and CVD mortality . Conclusions : Adherence to a Mediterranean dietary pattern was associated with reduced risk for cardiovascular mortality even in a developing country setting Background Decreasing salt consumption can prevent cardiovascular diseases ( CVD ) . Practically , it is difficult to promote people ’s awareness of daily salt intake and to change their eating habits in terms of reducing salt intake for better cardiovascular health . Health education programs visualizing daily dietary salt content and intake may promote lifestyle changes in patients at high risk of cardiovascular diseases . Methods / Design This is a cluster r and omized trial . A total of 800 high-CVD-risk patients attending diabetes and hypertension clinics at health centers in Muang District , Chiang Rai province , Thail and , will be studied with informed consent . A health center recruiting 100 participants is a cluster , the unit of r and omization . Eight clusters will be r and omized into intervention and control arms and followed up for 1 year . Within the intervention clusters the following will be undertaken : ( 1 )  salt content in the daily diet will be measured and shown to study participants ; ( 2 )  24-hour salt intake will be estimated in overnight-collected urine and the results shown to the participants ; ( 3 ) a dietician will assist small group health education classes in cooking meals with less salt . The primary outcome is blood pressure change at the 1-year follow-up . Secondary outcomes at the 1-year follow-up are estimated 24-hoursalt intake , incidence of CVD events and CVD death . The intention-to-treat analysis will be followed . Blood pressure and estimated 24-hour salt intake will be compared between intervention and control groups at the cluster and individual level at the 1-year follow-up . Clinical CVD events and deaths will be analyzed by time-event analysis . Retinal blood vessel calibers of CVD-risk patients will be assessed cross-sectionally . Behavioral change to reduce salt intake and the influencing factors will be determined by structured equation model ( SEM ) . Multilevel regression analyses will be applied . Finally , the cost effectiveness of the intervention will be analyzed . Discussion This study is unique as it will recruit the individuals most vulnerable to CVD morbidity and mortality by applying the general Framingham CVD risk scoring system . Dietary salt reduction will be applied as a prioritized , community level intervention for the prevention of CVD in a developing country . Trial registration IS RCT Background : Persons with chronic kidney disease ( CKD ) represent a population prone to cardiovascular disease ( CVD ) but vulnerable to adverse medication effects . We assessed the impact of intensive antihypertensive therapy on the cerebrovascular and other CVD outcomes in high-risk patients with type 2 diabetes and baseline CKD . Methods : Using current guideline criteria , 1,726 ( 36.9 % ) of 4,678 participants in the Action to Control Cardiovascular Risk in Diabetes ( ACCORD ) blood pressure ( BP ) arm had mild to moderate CKD ( CKD1 - 3B ) at baseline . Participants of this study were r and omized to intensive ( systolic < 120 mm Hg ) or st and ard ( systolic < 140 mm Hg ) BP goals . Fatal and non-fatal stroke were pre-specified secondary outcomes of the ACCORD study . Results : Total cerebrovascular events were significantly higher in participants with baseline CKD ( 0.66%/year ) compared with participants free of CKD ( 0.28%/year ) . A significantly higher rate of events was observed in CKD participants . Intensive antihypertensive therapy in participants without CKD at baseline result ed in a 55 % significant reduction of any stroke ( hazard ratio 0.447 ; 95 % CI 0.227 - 0.880 ) and a 50 % reduction of non-fatal stroke ( hazard ratio 0.498 ; 95 % CI 0.250 - 0.993 ) . In participants with CKD at baseline , the occurrence of any stroke was reduced by 38 % ( hazard ratio 0.623 ; 95 % CI 0.361 - 1.074 ) and non-fatal stroke by 36 % ( hazard ratio 0.642 ; 95 % CI 0.361 - 1.142 ) . Test for interaction was NS between the 2 groups . Changes in other CVD outcomes did not reach statistical significance . Conclusions : These findings suggest that intensive antihypertensive therapy offers significant cerebrovascular protection in diabetic participants without CKD at baseline , but significant benefit to patients with CKD can not be excluded OBJECTIVE Data sets regarding patients with abdominal aortic aneurysm ( AAA ) have almost universally been restricted to single geographic regions . We aim ed to obtain data on the risk factor profile and cardiovascular ( CV ) co-morbidity among multi-ethnic patients with known AAA in the global REACH ( REduction of Atherothrombosis for Continued Health ) Registry . METHODS The REACH Registry is an international , prospect i ve , observational out-patient registry enrolling out- patients > /=45 years of age with established coronary artery disease ( CAD ) , cerebrovascular disease ( CVD ) or peripheral arterial disease ( PAD ) or with at least three atherothrombotic risk factors . This report includes observations pertaining to 68,236 out- patients enrolled in 44 countries . MAIN OUTCOME MEASURES Gender , ethnic origin , CV risk factors , established atherosclerotic disease ( CAD , CVD and PAD ) at baseline , and CV outcome events at 1-year were compared in patients with and without AAA . RESULTS An AAA was reported in 1722 ( 2.5 % ) of 68,236 out- patients enrolled in the REACH Registry . Older age ( 73 + /- 8 vs 68 + /- 10 , P < .0001 ) , male gender ( 81 % vs 63 % , P < .0001 ) , White ethnicity ( 79 % vs 67 % , P < .0001 ) and a history of smoking ( 81 % vs 55 % , P < .0001 ) were independently related to the diagnosis of AAA . There was a weaker association with hypertension or hypercholesterolemia , and an inverse relation with diabetes . Fatal and non-fatal coronary and cerebrovascular event rates were not different between the AAA and non-AAA cohorts , but individuals with AAA suffered increased rates of other cardiovascular deaths ( 1.39 % vs 0.94 % , P = .0135 ) , hospitalizations for atherothrombotic events ( 14.1 % vs 9.3 % , P < .0001 ) due to increased rates of revascularization procedures , and new or worsening PAD ( 3.7 % vs 1.3 % , P < .0001 ) at 1-year follow-up . CONCLUSION This study , the largest published to date , presents the CV risk profile and outcome of patients with an established diagnosis of AAA from a cohort of patients with either overt manifestations of CV disease or multiple risk factors , and further defines these patients in a multi-ethnic , global context 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 This issue of JAMA contains the latest US Preventive Services Task Force ( USPSTF ) recommendation statement on statins for prevention of cardiovascular disease in adults,1 along with the accompanying evidence report and systematic review 2 on which the recommendations are based . The evidence report summarized data from 19 trials including a total of 71 344 patients and concluded that statin therapy was associated with reduced risk of all-cause and cardiovascular mortality and cardiovascular disease ( CVD ) events . Thus , the task force recommended “ initiating use of lowto moderate-dose statins in adults aged 40 to 75 years without a history of CVD who have 1 or more CVD risk factors and a calculated 10-year CVD event risk of 10 % or greater ( B recommendation ) ” or “ 7.5 % to 10 % ( C recommendation ) .”1 Although the task force did their usual careful job of review ing the evidence , the evidence for treating asymptomatic persons with statins does not appear to merit a grade B or even a grade C recommendation . The task force evidence report estimated an absolute benefit for use of statins of 0.40 % for all-cause mortality and 0.43 % for cardiovascular mortality and indicated that the absolute benefit was greater for patients at greater baseline risk.2 Notably , the evidence report did not exclude studies that included patients taking statins for secondary prevention , who have a higher baseline risk of cardiac events and death and thus are more likely to benefit from therapy that inflates the benefit attributed to a primary prevention population . The task force did perform a sensitivity analysis that excluded 3 trials with persons for whom there were prior “ hard ” cardiovascular events and obtained similar results of benefits ( eTable 5 in the article by Chou et al2 ) . This sensitivity analysis did not exclude WOSCOPS , which included patients receiving statins for secondary prevention—5 % had angina and 3 % had intermittent claudication,3 accounting for 15 % of the total weight in the meta- analysis . In contrast , a meta- analysis of 11 studies and 65 229 patients receiving statins for primary prevention , in which patients receiving statins for secondary prevention were excluded , found no benefit of statins for reducing all-cause mortality.4 The confidence intervals of these 2 analyses overlap , and the difference between these findings likely reflects differences in studies included . The USPSTF and authors of the evidence report did not have access to the primary data ( clinical study reports and anonymized patient-level data ) from the statin clinical trials . Rather , they had to rely on peer- review ed published reports as the basis for these recommendations . Exacerbating the potential bias , all of the trials included in the task force evidence report2 were industry-sponsored except 1 trial,5 and that trial contributed 0.2 % of the weight to the mortality calculation . Industry-sponsored studies have been shown to report greater benefit and lesser adverse effects than noncommercially sponsored trials of the same drugs.6 Whether this is true for statins and primary prevention of CVD is unknown . Among the 19 r and omized clinical trials of statins vs placebo or no statin included in the evidence report for the task force recommendations , only 15 reported all-cause mortality , 10 reported cardiovascular mortality , 12 reported fatal and nonfatal myocardial infa rct ion  , and 13 reported fatal and nonfatal stroke.2,7  Reliance on selective reporting of the most important outcomes , which are likely included in the clinical trial data , makes reporting bias possible . Furthermore , after allcause mortality , the comparative incidence of serious adverse events between treatment and control groups is arguably the second most important measure of the effect of active therapy in r and omized clinical trials . Underst and ing the evidence base in evaluating harms of statin therapy is also critically important . Although the benefits of any preventive therapy accrue according to risk of disease ( greater benefit in higher-risk patients ) , the harms of therapy usually distribute equally over all risk levels . Thus , persons at low risk have little chance of benefit but equal chance of harms and thus are more likely to have a net harm . The evidence base for harms of statins , despite the introduction of these drugs more than 20 years ago , is incomplete . Many of the trials did not ask about commonly reported statin effects , such as muscle pains and weakness , and only recorded myopathy , for which an increase in creatine kinase levels was required . Because most muscle problems do not involve an increase in creatine kinase levels , this leads to a significant underestimate of muscle problems . Other studies have estimated that closer to 20 % of statin users have muscle problems.8 Additionally , the actual trial data are largely held by the Cholesterol Treatment Trialists ’ Collaboration on behalf of the industry sponsor and have not been made available to other research ers , despite multiple requests over many years.9 Although reported rates of adverse events in clinical trials are low , this does not reflect the experience of clinicians who see patients who are taking statins . For instance , the experience of an NPR reporter with a calculated 2.9 % risk of heart disease over 10 years using the recommended American College of Cardiology/American Heart Association ( ACC/AHA ) risk calculator,10 but still prescribed a statin , and experiencing adverse effects from the medication , is typical of what many Related articles at jama.com The aim of this population -based , prospect i ve cohort study was to investigate long-term associations between dietary calcium intake  and fractures , non-fatal cardiovascular disease ( CVD ) , and death from all causes . Participants were from the Melbourne Collaborative Cohort Study , which was established in 1990 to 1994 . A total of 41,514 men and women ( ∼99 % aged 40 to 69 years at baseline ) were followed up for a mean ( SD ) of 12 ( 1.5 ) years . Primary outcome measures were time to death from all causes ( n = 2855 ) , CVD-related deaths ( n = 557 ) , cerebrovascular disease-related deaths ( n = 139 ) , incident non-fatal CVD ( n = 1827 ) , incident stroke events ( n = 537 ) , and incident fractures ( n = 788 ) . A total of 12,097 participants ( aged ≥50 years ) were eligible for fracture analysis and 34,468 for non-fatal CVD and mortality analyses .  Mortality was ascertained by record linkage to registries . Fractures and CVD were ascertained from interview ∼13 years after baseline . Quartiles of baseline energy-adjusted calcium intake from food were estimated using a food-frequency question naire . Hazard ratios ( HR ) and odds ratios ( OR ) were calculated for quartiles of dietary calcium intake . Highest and lowest quartiles of energy-adjusted dietary calcium intakes represented unadjusted means ( SD ) of 1348 ( 316 ) mg/d and 473 ( 91 ) mg/d , respectively . Overall , there were 788 ( 10.3 % ) incident fractures , 1827 ( 9.0 % ) incident CVD , and 2855 people ( 8.6 % ) died . Comparing the highest with the lowest quartile of calcium intake , for all-cause mortality , the HR was 0.86 ( 95 % confidence interval [ CI ] 0.76 - 0.98 , p(trend ) = 0.01 ) ; for non-fatal CVD and stroke , the OR was 0.84 ( 95 % CI 0.70 - 0.99 , p(trend ) = 0.04 ) and 0.69 ( 95 % CI 0.51 - 0.93 , p(trend ) = 0.02 ) , respectively ; and the OR for fracture was 0.70 ( 95 % CI 0.54 - 0.92 , p(trend ) = 0.004 ) . In summary , for older men and women , calcium intakes of up to 1348 ( 316 ) mg/d from food were associated with decreased risks for fracture , non-fatal CVD , stroke , and all-cause mortality Introduction Fewer than half of all people at highest risk of a cardiovascular event are receiving and adhering to best practice recommendations to lower their risk . In this project , we examine the role of an e-health-assisted consumer-focused strategy as a means of overcoming these gaps between evidence and practice . Consumer Navigation of Electronic Cardiovascular Tools ( CONNECT ) aims to test whether a consumer-focused e-health strategy provided to Aboriginal and Torres Strait Isl and er and non-indigenous adults , recruited through primary care , at moderate-to-high risk of a cardiovascular disease event will improve risk factor control when compared with usual care . Methods and analysis R and omised controlled trial of 2000 participants with an average of 18 months of follow-up to evaluate the effectiveness of an integrated consumer-directed e-health portal on cardiovascular risk compared with usual care in patients with cardiovascular disease or who are at moderate-to-high cardiovascular disease risk . The trial will be augmented by formal economic and process evaluations to assess acceptability , equity and cost-effectiveness of the intervention . The intervention group will participate in a consumer-directed e-health strategy for cardiovascular risk management . The programme is electronically integrated with the primary care provider 's software and will include interactive smart phone and Internet platforms . The primary outcome is a composite endpoint of the proportion of people meeting the Australian guideline -recommended blood pressure ( BP ) and cholesterol targets . Secondary outcomes include change in mean BP and fasting cholesterol levels , proportion meeting BP and cholesterol targets separately , self-efficacy , health literacy , self-reported point prevalence abstinence in smoking , body mass index and waist circumference , self-reported physical activity and self-reported medication adherence . Ethics and dissemination Primary ethics approval was received from the University of Sydney Human Research Ethics Committee and the Aboriginal Health and Medical Research Council . Results will be disseminated via the usual scientific forums including peer- review ed publications and presentations at international conferences Clinical Trials registration number ACTRN12613000715774 BACKGROUND Primary prevention of cardiovascular disease (CVD),by identifying individuals at risk is a well-established , but costly strategy when based on measurements that depend on laboratory analyses . A non-laboratory , paper-based CVD risk assessment chart tool has previously been developed to make screening more affordable in developing countries . Task shifting to community health workers ( CHWs ) is being investigated to further scale CVD risk screening . This study aim ed to develop a mobile phone CVD risk assessment application and to evaluate its impact on CHW training and the duration of screening for CVD in the community by CHWs . METHODS A feature phone application was developed using the open source online platform , CommCare ( © ) . CHWs ( n=24 ) were trained to use both paper-based and mobile phone CVD risk assessment tools . They were r and omly allocated to using one of the risk tools to screen 10 - 20 community members and then crossed over to screen the same number , using the alternate risk tool . The impact on CHW training time , screening time and margin of error in calculating risk scores was recorded . A focus group discussion evaluated experiences of CHWs using the two tools . RESULTS The training time was 12.3h for the paper-based chart tool and 3h for the mobile phone application . 537 people were screened . The mean screening time was 36 min ( SD=12.6 ) using the paper-base chart tool and 21 min ( SD=8.71 ) using the mobile phone application , p=<0.0001 . Incorrect calculations ( 4.3 % of average systolic BP measurements , 10.4 % of BMI and 3.8 % of CVD risk score ) were found when using the paper-based chart tool while all the mobile phone calculations were correct . Qualitative findings from the focus group discussion corresponded with the findings of the pilot study . CONCLUSION The reduction in CHW training time , CVD risk screening time , lack of errors in calculation of a CVD risk score and end user satisfaction when using a mobile phone application , has implication s in terms of adoption and sustainability of this primary prevention strategy to identify people with high CVD risk who can be referred for appropriate diagnoses and treatment The use of preventive medications in people at high risk of cardiovascular disease is conceptually straightforward , yet in practice the adoption of such measures is disappointingly low , plus there is wide international variation in preventive therapies . Several barriers might explain this shortfall and variation , but the simplicity and economy of a polypill-based strategy might overcome some barriers . The ‘ Use of a Multidrug Pill In Reducing cardiovascular Events ’ ( UMPIRE ) trial assesses whether a polypill strategy ( by combining aspirin , a statin and two blood pressure lowering agents ) would improve adherence to guideline -indicated therapies and would lower both blood pressure and cholesterol , in people with established cardiovascular disease . UMPIRE , running in India and three European countries ( Engl and , Irel and and the Netherl and s ) , is an open , r and omised , controlled trial design ed to include 1000 participants in India and 1000 in Europe , with a followup of 12–24 months . Participants were r and omised to one of two versions of the polypill or relegated to usual care . The primary study outcomes were the self-reported use of aspirin , a statin and at least two blood pressure lowering agents ; as well as changes in blood pressure and cholesterol . Secondary outcomes included : any cardiovascular events , reasons for stopping medications , serious adverse events and perceived changes in quality of life . Interpretation of the study data will be enhanced by health , economic and process-related evaluations . UMPIRE is registered with the European Clinical Trials data base , as EudraCT : 2009 - 016278 - 34 and the Clinical Trials Registry , India as CTRI/2010/091/000250 . The trial was part of the ‘ Single Pill Against Cardiovascular Events ( SPACE ) ’ collaboration , which encompasses the ‘ IMProving Adherence using Combination Therapy ( IMPACT ) ’ and ‘ Kanyini Guidelines Adherence with the Polypill ( Kanyini-GAP ) ’ trials Cost-effective strategies to maintain healthy active lifestyle in aging population s are required to address the global burden of age-related diseases . ASPREE will examine whether the potential primary prevention benefits of low dose aspirin outweigh the risks in older healthy individuals . Our primary hypothesis is that daily oral 100 mg enteric-coated aspirin will extend a composite primary endpoint termed ' disability-free life ' including onset of dementia , total mortality , or persistent disability in at least one of the Katz Activities of Daily Living in 19,000 healthy participants aged 65 years and above ( ' US minorities ' ) and 70 years and above ( non-'US minorities ' ) . ASPREE is a double-blind , r and omized , placebo-controlled trial of oral 100 mg enteric-coated acetyl salicylic acid ( ASA ) or matching placebo being conducted in Australian and US community setting s on individuals free of dementia , disability and cardiovascular disease ( CVD ) events . Secondary endpoints are all-cause and cause specific mortality , fatal and non-fatal cardiovascular events , fatal and non-fatal cancer ( excluding non-melanoma skin cancer ) , dementia , mild cognitive impairment , depression , physical disability , and clinical ly significant bleeding .  To 20 September 2013 14,383 participants have been recruited . Recruitment and study completion are anticipated in July 2014 and December 2018 respectively . In contrast to other aspirin trials that have largely focused on cardiovascular endpoints , ASPREE has a unique composite primary endpoint to better capture the overall risk and benefit of aspirin to extend healthy independent lifespan in older adults in the US and Australia The Systolic Blood Pressure Intervention Trial ( SPRINT ) is a large National Institutes of Health– sponsored multicenter r and omized controlled trial that enrolled 9361 patients with a systolic blood pressure ( SBP ) of at least 130 mm Hg . The primary goal of SPRINT was to test whether reducing SBP to a lower goal ( < 120 mm Hg ) than currently recommended ( < 140 mm Hg ) would reduce the occurrence of cardiovascular disease ( CVD ) and chronic kidney disease ( CKD ) events . Enrolled patients were 50 years or older with an SBP ≥130 mm Hg and at least one of the following : a history of CVD , stage 3 CKD ( estimated glomerular filtration rate 20–59 mL/min/1.73 m ) , an intermediate to high risk for CVD other than stroke , or age 75 years or older . A patient was defined as having CVD if they had a prior myocardial infa rct ion , percutaneous coronary intervention , coronary artery bypass grafting , carotid endarterectomy or carotid stenting , peripheral arterial disease with revascularization , acute coronary syndrome , abdominal aortic aneurysm ≥5 cm with or without repair , a coronary calcium score > 400 , or left ventricular hypertrophy . Patients were defined as at intermediate or high risk for CVD based on the following : Framingham Risk Score for 10-year CVD risk of 15 % based on laboratory work performed for lipids within the past 12 months . The primary outcome was a composite of cardiovascular events . The SPRINT study was terminated early after 3.26 years on advisory of the data safety monitoring board . The results of the SPRINT study showed a 25 % reduction in the primary combined cardiovascular outcome and a 27 % reduction in mortality in the group r and omized to SBP < 120 mm Hg . This obviously has important implication s for blood pressure ( BP ) guidelines in this population . The baseline mean systolic and diastolic BPs were 139.7 mm Hg and 78.1 mm Hg , respectively . At 1 year , the mean SBP was 121.4 mm Hg in the intensive treatment group and 136.2 mm Hg in the st and ard treatment group . The SPRINT study included 28 % of patients with CKD , 28 % of patients were older than 75 years , 36 % were women , and 20 % had prior CVD . The sample was diverse and included 29.9 % black , 10.5 % Hispanic , and 57.7 % white patients .  Importantly , SPRINT excluded many patients with hypertension . Who were these population s ? The following groups of patients with hypertension were excluded : those with a history of prior stroke , diabetes , polycystic kidney disease , any secondary cause for hypertension , glomerular filtration rate ( GFR ) < 20 cc/ min , > 1 g of proteinuria per 24 hours , glomerulonephritis treated with immunosuppressive therapy , symptomatic heart failure within the past 6 months or left ventricular ejection fraction < 35 % , expected survival less than 3 years , cancer diagnosed within the past 2 years , organ transplant , cardiovascular event , procedure or hospitalization for unstable angina within the past 3 months , and all patients younger than 50 years . Why were these patients excluded ? Patients with diabetes were excluded as it was felt that this population had already been studied in the Action to Control Cardiovascular Risk in Diabetes ( ACCORD ) BP trial , which did not show a cardiovascular advantage of lower SBP ( < 120 mm Hg ) vs st and ard BP ( < 140 mm Hg ) although there was a decreased risk of stroke .  Patients with polycystic kidney disease have also been studied separately in the HALT Progression of Polycystic Kidney Disease study , which recently showed that rigorous BP control was associated with a slower increase in total kidney volume , no overall change in the estimated GFR , a greater decline in the left ventricular mass index , and greater reduction in urinary albumin excretion .  Patients with excessive proteinuria > 1 g per 24 hours were also excluded , but , based on data from the Modification of Diet in Renal Disease ( MDRD ) , the Blood Pressure Control for Renoprotection in Patients With Nondiabetic Chronic Renal Disease ( REIN ) , and the African American Study of Kidney Disease and Hypertension ( AASK ) studies , lower BP goals ( < 130/80 mm Hg ) have been suggested and recommended by some guidelines in this patient population . Renal transplant recipients were excluded in this population . There are no r and omized controlled trials examining optimal levels of BP and this is a population that needs to be studied . BP threshold for treatment of kidney transplant recipients remains at 130/80 mm Hg , regardless of proteinuria . The Secondary Prevention of Small Subcortical Strokes ( SPS3 ) trial , which compared an SBP treatment target of < 130 mm Hg with a target of 130 mm Hg to 149 mm Hg in participants with a recent lacunar stroke , showed a nonsignificant reduction in recurrent stroke in the group r and omized to the lower target . There are no specific studies that have evaluated BP targets in patients without other comorbidities who are Address for correspondence : Debbie L. Cohen , MD , Renal , Electrolyte and Hypertension Division , Perelman School of Medicine at the University of Pennsylvania , 1 Founders Building , 3400 Spruce Street , Philadelphia , PA 19104 E-mail : Background Cardiovascular disease ( CVD ) is the leading cause of early death worldwide , responsible for an estimated 29 % of all global deaths . Reducing salt intake lowers blood pressure and risk of secondary cardiac events . However , identifying low salt foods can be challenging . SaltSwitch is a simple smartphone application ( app ) that enables shoppers to scan the barcode of packaged foods and receive an immediate , interpretive , traffic light nutrition label on the screen , along with suggestions for healthier lower-salt alternatives . A growing body of evidence suggests mobile technologies can support healthy behaviour change . However , robust evidence for the impact of smartphone interventions is lacking . This manuscript outlines the rationale and methods for a r and omized controlled trial design ed to determine the effectiveness of SaltSwitch in supporting people with CVD to make lower-salt food choices . Design / Methods A 6-week , two-arm , parallel , r and omized controlled trial is being undertaken in New Zeal and ( 2 weeks baseline and 4 weeks intervention ) . Three hundred adults aged 40 years and older with CVD and their main household shoppers are recruited from research lists , cardiac rehabilitation clinics , and communities in Auckl and . Participants are r and omized to receive either the SaltSwitch smartphone app or no intervention ( control ) . R and omisation is stratified by ethnicity and age . The primary outcome is the salt content of household food purchases . Secondary outcomes are the saturated fat and energy content of household food purchases , household food expenditure , use and acceptability of the SaltSwitch app by shoppers , and urinary sodium and blood pressure of participants with CVD . Ambulatory blood pressure and potential longer-term impact ( 12 weeks ) of SaltSwitch will be assessed in sub- studies ( n ~ 40 and n ~ 20 , respectively ) . Household purchases of salt and other nutrients will be assessed using till receipt data electronically linked with br and ed food composition data . Discussion The results of the SaltSwitch trial will determine the effectiveness , use and acceptability of a smartphone application to support lower salt food choices and secondary prevention of CVD.Trial registration ACTRN12614000206628 . Registered 30 March 2014 OBJECTIVES To assess the efficacy of a comprehensive secondary prevention programme to reduce morbidity and mortality in patients who have suffered a cardiovascular ( CV ) event ; to control CV risk factors and prophylactic treatment in order to prevent recurrence ; and to improve the quality of life of patients with cardiovascular disease . DESIGN R and omised , pragmatic , open clinical trial in primary care . SETTING A total of 42 primary care centres of 8 different areas in Spain . PARTICIPANTS Men and women below 86 years old , diagnosed with coronary disease and /or stroke and /or peripheral vascular disease in the preceding year , and who have no serious or terminal disease . INTERVENTION Primary care centres will be r and omised to following usual care ( control group ) , or to following a comprehensive programme of secondary prevention ( intervention group ) . MAIN MEASUREMENTS Cardiovascular fatal events , cardiovascular non-fatal events , total mortality and health-related quality of life ( SF-36 ) Background —Few data have evaluated physician adherence to cardiovascular disease ( CVD ) prevention guidelines according to physician specialty or patient characteristics , particularly gender . Methods and Results —An online study of 500 r and omly selected physicians ( 300 primary care physicians , 100 obstetricians/gynecologists , and 100 cardiologists ) used a st and ardized question naire to assess awareness of , adoption of , and barriers to national CVD prevention guidelines by specialty . An experimental case study design tested physician accuracy and determinants of CVD risk level assignment and application of guidelines among high- , intermediate- , or low-risk patients . Intermediate-risk women , as assessed by the Framingham risk score , were significantly more likely to be assigned to a lower-risk category by primary care physicians than men with identical risk profiles ( P<0.0001 ) , and trends were similar for obstetricians/gynecologists and cardiologists . Assignment of risk level significantly predicted recommendations for lifestyle  and preventive pharmacotherapy . After adjustment for risk assignment , the impact of patient gender on preventive care was not significant except for less aspirin ( P<0.01 ) and more weight management recommended ( P<0.04 ) for intermediate-risk women . Physicians did not rate themselves as very effective in their ability to help patients prevent CVD . Fewer than 1 in 5 physicians knew that more women than men die each year from CVD . Conclusions —Perception of risk was the primary factor associated with CVD preventive recommendations . Gender disparities in recommendations for preventive therapy were explained largely by the lower perceived risk despite similar calculated risk for women versus men . Educational interventions for physicians are needed to improve the quality of CVD preventive care and lower morbidity and mortality from CVD for men and women Objectives In many current guidelines , blood pressure (BP)-lowering drug treatment for primary prevention of cardiovascular disease ( CVD ) is based on absolute risk . However , in clinical practice , therapeutic decisions are often based on BP levels alone . We sought to investigate which approach was superior by conducting a post hoc analysis of the Australian National Blood Pressure ( ANBP ) cohort , a seminal study establishing the efficacy of BP lowering in ‘ mild hypertensive ’ persons . Design A post hoc subgroup analysis of the ANBP trial results by baseline absolute risk tertile . Setting and participants 3244 participants aged 35–69 years in a community-based r and omised placebo controlled trial of blood pressure-lowering medication . Interventions Chlorothiazide500 mg versus placebo . Primary outcome measures All-cause mortality and non-fatal events ( non-fatal CVD , congestive cardiac failure , renal failure , hypertensive retinopathy or encephalopathy ) . Results Treatment effects were assessed by HR , absolute risk reduction and number needed to treat . Participants had an average 5-year CVD risk in the intermediate range ( 10.5±6.5 ) with moderately elevated BP ( mean 159/103 mmHg ) and were middle aged ( 52±8 years ) . In a subgroup analysis , the relative effects ( HR ) and absolute effects ( absolute risk reduction and number needed to treat ) did not statistically differ across the three risk groups except for the absolute benefit in all-cause mortality ( p for heterogeneity=0.04 ) . With respect to absolute benefit , drug treatment significantly reduced the number of events in the high-risk group regarding any event with a number needed to treat of 18 ( 10 to 64 ) , death from any cause with 45 ( 25 to 196 ) and major CVD events with 23 ( 12 to 193 ) . Conclusion Our analysis confirms that the benefit of treatment was substantial only in the high-risk tertile , reaffirming the rationale of treating elevated blood pressure in the setting of all risk factors rather than in isolation Objectives : Current blood pressure ( BP ) management guidelines recommend that treatment thresholds for BP be based on absolute cardiovascular disease ( CVD ) risk rather than on elevated BP levels alone . Clinicians are concerned that delayed pharmacotherapy in individuals with high BP , but low CVD risk , may increase long-term CVD events . To investigate this , we examined differences in CVD events within the Second Australian National BP study ( ANBP2 ) for those previously on pharmacotherapy and those who were not , as well as fatal events in the 6-year post-trial period . Methods : Population consisted of ANBP2 participants without a prior CVD event . Adjusted Cox-regression hazard models were used to assess the effects of prior BP pharmacotherapy use on cardiovascular endpoints within ANBP2 . An extended 6-year follow-up analysis for cardiovascular and all-cause mortality was also conducted . Results : We found a higher in-trial CVD and all-cause mortality rate and incidence of new-onset diabetes for those on previous treatment versus those who were treatment-naive . We investigated whether this was an effect of the in-trial protocol , but this did not explain the observed differences . No difference in CVD or all-cause mortality at 10 years was observed between ‘ treatment-naive ’ and ‘ previous treatment ’ groups . Conclusion : We found no long-term adverse mortality associated with treatment naivety of elevated BP in an elderly hypertensive cohort , but this finding is likely to be confounded as seen by the lower in-trial mortality in the ‘ treatment-naive ’ group . Legacy effects need to be explored in r and omized trials of middle-aged population s where the clinical concern lies BACKGROUND Many strategies have been evaluated to improve the prevention and control of cardiovascular ( CVD ) risk factors . Nursing telephonic and tele-counseling individualized lifestyle educational programs have been found to improve blood pressure control and adherence to lifestyle recommendation . This study tested the efficacy of a nurse-led reminder program through email ( NRP-e ) to improve CVD risk factors among hypertensive adults . METHODS All participants received usual CVD prevention and a guideline -based educational program . Subjects in the NRP-e group also received weekly email alerts and phone calls from a nurse care manager for 6 months . Emails contained a reminder program on the need for adherence with a healthy lifestyle based upon current guidelines . Follow-up visits were scheduled at 1 , 3 and 6 months after enrollment ; r and omization was made central ly and blood sample s were evaluated into a single laboratory . RESULTS The final sample consisted of 98 ( control ) and 100 ( NRP-e ) subjects ( mean age 59.0 ± 14.5 years ; 51.0 % males ) . After 6 months , the following CVD risk factors significantly improved in both groups : body mass index , alcohol and fruit consumption , cigarette smoking , adherence to therapy hours , systolic and diastolic blood pressure , fasting blood glucose , low-density lipoproteins ( LDL ) and total cholesterol , triglycerides , and physical activity . In the NRP-e group , however , the prevalence of several behaviors or conditions at risk decreased significantly more than in the control group : obesity ( -16 % ) , low fruit consumption ( -24 % ) , uncontrolled hypertension ( -61 % ) , LDL ( -56 % ) , and total cholesterol ( -40 % ) . CONCLUSIONS The NRP-e improved a range of CVD risk factors . The program had low costs , required only an average of < 20 min per day in addition to normal practice , and may deserve further evaluation for the inclusion among existing care management approaches We assessed the importance of Streptococcus pneumoniae and immunologic response to 14-valent pneumococcal vaccine in a r and omized ( saline placebo or vaccine ) double-blind pilot study involving 103 patients with chronic obstructive pulmonary disease ( COPD ) .  Antibody titers , the flora of the sputum , respiratory infections or pneumonias , and deaths were monitored . The patients ' antibody titers before immunization were higher than healthy control subjects . Titers rose normally in those vaccinated but declined more rapidly . Differences between the group receiving placebo and vaccine were not significant at 12 and 24 months . The incidence of pneumonia was high before and after vaccine ( 47/1,000 vs 41/1,000 patient-years ) . Nonpneumococcal causes predominated ( 73 percent of pneumonias ; 83.4 percent of lethal pneumonias ) . Isolates from sputum were predominantly nonvaccine types ( 50 to 62.5 percent ) . Twenty-seven patients died ; pneumonia occurred in six ( one pneumococcal in a vaccinated patient ) as a terminal complication of other diseases . Thus , although pneumonia occurred frequently in these patients with COPD and contributed to mortality in 22 percent ( six ) of the 27 deaths , the predominance of nonpneumococcal causes and the data on antibodies and sputum suggest that pneumococcal vaccine may not be as beneficial for patients with COPD as was hoped . More observations are needed BACKGROUND The identification of persons at high cardiovascular risk is of primary importance in the context of cardiovascular prevention . Accuracy and precision of risk assessment are essential properties . We developed a calibrated SCORE risk chart ( Systematic COronary Risk Evaluation ) for calculating the absolute 10-year probability of developing a fatal cardiovascular event , adapted to national mortality statistics and risk factor distributions in Belgium and critically evaluated its predictive accuracy . METHODS Our SCORE Belgium risk chart was vali date d using data from 6212 non-diabetic men and women free of CHD participating in a prospect i ve cohort study carried out in the eighties ( Belgian Interuniversity Research on Nutrition and Health ) . Agreement between numbers of predicted and observed CVD deaths across the entire spread of risk was studied using chi-square and Hosmer-Lemeshow statistics . Discriminatory power of risk estimates was evaluated according to Harrell 's c-statistic . RESULTS During the period of 10 years , 274 CVD deaths were observed while the recalibrated risk chart predicted 263 events . The SCORE Belgium risk chart showed very good accuracy over the complete range of predicted risk ( Hosmer-Lemeshow : P=0.14 ) . ROC analysis revealed excellent discriminatory power in labelling future cases of fatal cardiovascular disease with a c-statistic of 0.86 . The 5 % threshold for the probability of 10-year cardiovascular death yielded an optimal balance of sensitivity and specificity . CONCLUSIONS The SCORE Belgium risk chart proves to be well suited as an accurate and precise estimation tool for the assessment of cardiovascular risk in Belgium BACKGROUND Coronary artery calcium ( CAC ) and carotid intima-media thickness ( IMT ) are noninvasive measures of atherosclerosis that consensus panels have recommended as possible additions to risk factor assessment for predicting the probability of cardiovascular disease ( CVD ) occurrence . Our objective was to assess whether maximum carotid IMT or CAC ( Agatston score ) is the better predictor of incident CVD . METHODS A prospect i ve cohort study of subjects aged 45 to 84 years in 4 ethnic groups , who were initially free of CVD ( n = 6698 ) was performed , with st and ardized carotid IMT and CAC measures at baseline , in 6 field centers of the Multi-Ethnic Study of Atherosclerosis ( MESA ) . The main outcome measure was the risk of incident CVD events ( coronary heart disease , stroke , and fatal CVD ) over a maximum of 5.3 years of follow-up . RESULTS There were 222 CVD events during follow-up . Coronary artery calcium was associated more strongly than carotid IMT with the risk of incident CVD . After adjustment for each other ( CAC score and IMT ) and age , race , and sex [ corrected ] , the hazard ratio of CVD increased 2.1-fold ( 95 % confidence interval [ CI ] , 1.8 - 2.5 ) for each 1-st and ard deviation ( SD ) increment of log-transformed CAC score , vs 1.3-fold ( 95 % CI , 1.1 - 1.4 ) for each 1-SD increment of the maximum IMT . For coronary heart disease , the hazard ratios per 1-SD increment increased 2.5-fold ( 95 % CI , 2.1 - 3.1 ) for CAC score and 1.2-fold ( 95 % CI , 1.0 - 1.4 ) for IMT . A receiver operating characteristic curve analysis also suggested that CAC score was a better predictor of incident CVD than was IMT , with areas under the curve of 0.81 vs 0.78 , respectively . CONCLUSION Although whether and how to clinical ly use bioimaging tests of sub clinical atherosclerosis remains a topic of debate , this study found that CAC score  is a better predictor of subsequent CVD events than carotid IMT Background and Research Objective : The incidence of cardiovascular disease ( CVD ) is particularly high among African American ( AA ) older adults , and these individuals are least likely to have access to CVD prevention activities . The purpose of this study was to test the feasibility of People Reducing Risk and Improving Strength through Exercise , Diet and Drug Adherence ( PRAISEDD ) , which is geared at increasing adherence to CVD prevention behaviors among AA and low-income older adults . Methods : This feasibility study was conducted in a senior housing site , using a single-group repeated- measures design and testing  physical activity , diet , medication adherence beliefs and behaviors , and blood pressure at baseline and after a 12-week intervention period . Of 22 participants , mean ( SD ) age was 76.4 ( 7.6 ) years , and most were female ( 64 % ) and AA ( 86 % ) . An intention-to-treat analysis was used . Results : There were significant decreases in systolic ( P = .02 ) and diastolic blood pressure ( P = .01 ) and a nonsignificant trend toward improvement in cholesterol intake ( P = .09 ) . There were no changes in time spent in moderate-level physical activity , sodium intake , medication adherence , or self-efficacy and outcome expectations across all 3 behaviors . Conclusion : The PRAISEDD intervention was feasible in a group of AA and low-income older adults and , after 12 weeks , result ed in improvements in blood pressure . Future research is needed to test a revised PRAISEDD intervention using a r and omized controlled design , a larger sample , and a longer follow-up period . The PRAISEDD intervention should be revised to incorporate environmental and policy changes that influence CVD prevention behaviors and explore the impact of social networking as it relates to diffusion of the intervention among participants in low-income housing facilities Background Because of a high cardiovascular disease ( CVD ) risk in people with Familial Hypercholesterolemia ( FH ) , early prevention of cardiovascular disease is important for health gain and cost reduction . This project focuses on the development and evaluation of an innovative intervention aim ing to reduce CVD risk by promoting a healthy lifestyle among people with FH . Methods This project is design ed as a r and omised controlled trial in which individuals with FH will be assigned r and omly to a control or intervention group . In the intervention group ( n = 200 ) , participants will receive a personalized intervention which is a combination of web-based tailored lifestyle advice and personal counselling by a lifestyle coach .  The control group ( n = 200 ) will receive care as usual . Primary outcomes are biological indicators of CVD risk : systolic blood pressure , glucose , BMI , waist circumference and lipids ( triglycerides , total , LDL and HDL cholesterol ) . Secondary outcomes are : healthy lifestyle behaviour ( with regard to smoking , physical activity , dietary pattern and compliance to statin therapy ) and psychological correlates and determinants of healthy lifestyle behaviour ( knowledge , attitude , risk perception , social influence , self-efficacy , cues to action , intention and autonomy ) . Measurement will take place at baseline , and at 3 and 12 months after r and omisation . Additionally , a throughout process-evaluation will be conducted to assess and monitor intervention implementation during the trial . Discussion Results of the PRO-FIT project will provide information about the effects and implementation of a healthy lifestyle intervention for individuals with FH . Our experiences with this intervention will be indicative about the suitability , feasibility and benefits of this approach for future interventions in other high-risk groups , such as Familial Combined Hypercholesterolemia ( FCH ) and diabetes . Trial registration Background There is consistent evidence on the impact of health behaviours on risk of cardiovascular disease ( CVD ) in European population s. As South Asians in the UK have an excess risk of CVD and coronary heart disease ( CHD ) compared to Europeans , we investigated whether a similar association between combined health behaviours and risk of CVD and CHD among this high-risk group exists , and estimated the population impact . Methods and Findings In a prospect i ve cohort of 1090 Europeans and 1006 South Asians ( 40–69 y ) without prevalent CVD at baseline ( 1988–1990 ) , followed up for 21 years to 2011 , there were 601 incident CVD events [ Europeans n = 255 ; South Asians n = 346 ] of which 520 were CHD events [ n = 207 and 313 respectively ] . Participants scored between 0 to 4 points for a composite score including four baseline healthy behaviours ( non-smoker , moderate alcohol intake , physically active , frequent fruit/vegetable intake ) . Adjusted hazard ratios ( 95 % confidence intervals ) for incident CHD in Europeans who had three , two , one , and zero compared to four health behaviours were 1.33 ( 0.78–2.29 ) , 1.96 ( 1.15–3.33 ) , 1.36 ( 0.74–2.48 ) and 2.45 ( 1.18–5.10 ) , respectively , p-trend = 0.025 . In South Asians , corresponding HRs were 2.88 ( 1.33–6.24 ) , 2.28 ( 1.06–4.91 ) , 3.36 ( 1.53–7.39 ) and 3.48 ( 1.38–8.81 ) , p-trend = 0.022 . The results were similar for incident CVD ; Europeans HR 2.12 ( 1.14–3.94 ) , p – trend = 0.014 ; South Asians HR 2.73 ( 1.20–6.21 ) , p-trend = 0.018 . The population attributable fraction in Europeans was 43 % for CHD and 28 % for CVD . In South Asians it was 63 % and 51 % respectively . Conclusions Lack of adherence to four combined health behaviours was associated with 2 to 3-fold increased risk of incident CVD in Europeans and South Asians . A substantial population impact in the South Asian group indicates important potential for disease prevention in this high-risk group by adherence to healthy behaviours Background Many preventable behaviors contribute to adolescent mortality and morbidity . Non-adherence to preventive measures represents a challenge and has been associated with worse health outcomes in this population . The widespread use of electronic communication technologies by adolescents , particularly the use of text messaging ( short message service , SMS ) and mobile phones , presents new opportunities to intervene on risk and preventive risk behavior , but little is known about their efficacy . Objective This study aim ed to systematic ally evaluate evidence for the efficacy of text messaging and mobile phone app interventions to improve adherence to preventive behavior among adolescents and describe intervention approaches to inform intervention development . Methods This review covers literature published between 1995 and 2015 . Search es included PubMed , Embase , CENTRAL , PsycINFO , CINAHL , INSPEC , Web of Science , Google Scholar , and additional data bases . The search strategy sought articles on text messaging and mobile phone apps combined with adherence or compliance , and adolescents and youth . An additional h and search of related themes in the Journal of Medical Internet Research was also conducted . Two review ers independently screened titles and abstract s , assessed full-text articles , and extracted data from articles that met inclusion criteria . Included studies reflect original research —experimental or preexperimental design s with text messaging or mobile phone app interventions —targeting adherence to preventive behavior among adolescents ( 12 - 24 years old ) . The preferred reporting items of systematic review s and meta-analyses ( PRISMA ) guidelines were followed for reporting results , and findings were critically appraised against the Oxford Centre for Evidence -based Medicine criteria . Results Of 1454 records , 19 met inclusion criteria , including text messaging ( n=15 ) and mobile phone apps ( n=4 ) . Studies targeted clinic attendance , contraceptive use , oral health , physical activity and weight management , sun protection , human papillomavirus ( HPV ) vaccination , smoking cessation , and sexual health .  Most studies were performed in the United States ( 47 % , 9/19 ) , included younger adolescents ( 63 % , 12/19 ) , and had sample size < 100 ( 63 % , 12/19 ) . Although most studies were r and omized controlled trials ( RCTs ; 58 % , 11/19 ) , only 5 followed an intent-to-treat analysis . Only 6 of 19 studies ( 32 % ) incorporated a theoretical framework in their design . Most studies reported good feasibility with high acceptability and satisfaction . About half of the included studies ( 42 % , 8/19 ) demonstrated significant improvement in preventive behavior with moderate st and ardized mean differences . As early efforts in this field to establish feasibility and initial efficacy , most studies were low to moderate in quality . Studies varied in sample size and methods of preventive behavior adherence or outcome assessment , which prohibited performing a meta- analysis . Conclusions Despite the promising feasibility and acceptability of text messaging and mobile phone apps in improving preventive behavior among adolescents , overall findings were modest in terms of efficacy . Further research evaluating the efficacy , effectiveness , and cost-effectiveness of these intervention approaches in promoting preventive behavior among adolescents is needed Background Maintaining a healthy weight and undertaking regular physical activity are important for the secondary prevention of cardiovascular disease ( CVD ) . However , many people with CVD are overweight and insufficiently active . In addition , in Australia only 20 - 30 % of people requiring cardiac rehabilitation ( CR ) for CVD actually attend . To improve outcomes of and access to CR the efficacy , effectiveness and cost-effectiveness of alternative approaches to CR need to be established . This research will determine the efficacy of a telephone-delivered lifestyle intervention , promoting healthy weight and physical activity , in people with CVD in urban and rural setting s. The control group will also act as a replication study of a previously proven physical activity intervention , to establish whether those findings can be repeated in different urban and rural locations . The cost-effectiveness and acceptability of the intervention to CR staff and participants will also be determined . Methods / Design This study is a r and omised controlled trial . People referred for CR at two urban and two rural Australian hospitals will be invited to participate . The intervention ( healthy weight ) group will participate in four telephone delivered behavioural coaching and goal setting sessions over eight weeks . The coaching sessions will be on weight , nutrition and physical activity and will be supported by written material s , a pedometer and two follow-up booster telephone calls . The control ( physical activity ) group will participate in a six week intervention previously shown to increase physical activity , consisting of two telephone delivered behavioural coaching and goal setting sessions on physical activity , supported by written material s , a pedometer and two booster phone calls . Data will be collected at baseline , eight weeks and eight months for the intervention group ( baseline , six weeks and six months for the control group ) . The primary outcome is weight change . Secondary outcomes include physical activity , sedentary time and nutrition habits . Costs will be compared with outcomes to determine the relative cost-effectiveness of the healthy weight and physical activity interventions . Discussion This study addresses a significant gap in public health practice by providing evidence for the efficacy and cost-effectiveness of a low cost , low contact , high reach intervention promoting healthy weight and physical activity among people with CVD in rural and urban areas in Australia . The replication arm of the study , undertaken by the control group , will demonstrate whether the findings of the previously proven physical activity intervention can be generalised to new setting s. This population -based approach could potentially improve access to and outcomes of secondary prevention programs , particularly for rural or disadvantaged communities . Trial Registration BACKGROUND With few exceptions , tools used to estimate cardiovascular disease ( CVD ) risk in those without prior events are based mainly on data from middle-aged subjects . Given the ever increasing number of older people , many with hypertension , a risk score relevant to this group is warranted . Our aim was to develop a cardiovascular risk equation suitable for risk prediction in elderly , hypertensive population s. METHODS We utilized  cardiovascular end point data from 4.1 years median follow-up in 5,426 hypertensive subjects without previous CVD from the Second Australian National Blood Pressure Study ( ANBP2 ) . Our risk model , based on Cox regression , was developed using 75 % of subjects without evident CVD ( n = 4,072 ) , r and omly selected and stratified by age and gender , and internally vali date d using the remaining 25 % . The model was also externally vali date d against the Dubbo Study data set . RESULTS The final model included sex , age , physical activity in the 2 weeks prior to entry into study , family history , use of anticoagulants , central ly acting antihypertensive agents or diabetes medication , and an interaction term for sex and diabetes medication . The C-statistic was 0.65 ( 0.62 - 0.67 ) for our predictive model on the model development data set and 0.62 ( 0.57 - 0.67 ) on the internal validation data set . The Dubbo Data C-statistic for CVD was 0.68 ( 95 % CI 0.65 - 0.71 ) . CONCLUSIONS All models performed similarly . Because of greater ease of implementation , we recommend that existing algorithms be extended into older age groups BACKGROUND Psychosocial factors are independently associated with increased risk of cardiovascular disease ( CVD ) morbidity and mortality , but the effects of psychosocial factor intervention on CVD are uncertain . We performed a r and omized controlled clinical trial of cognitive behavioral therapy ( CBT ) to measure its effects on CVD recurrence . METHODS The study included 362 women and men 75 years or younger who were discharged from the hospital after a coronary heart disease event within the past 12 months . Patients were r and omized to receive traditional care  ( reference group , 170 patients ) or traditional care plus a CBT program ( intervention group , 192 patients ) , focused on stress management , with 20 two-hour sessions during 1 year . Median attendance at each CBT session was 85 % . Outcome variables were all-cause mortality , hospital admission for recurrent CVD , and recurrent acute myocardial infa rct ion . RESULTS During a mean 94 months of follow-up , the intervention group had a 41 % lower rate of fatal and nonfatal first recurrent CVD events ( hazard ratio [ 95 % confidence interval ] , 0.59 [ 0.42 - 0.83 ] ; P = .002 ) , 45 % fewer recurrent acute myocardial infa rct ions ( 0.55 [ 0.36 - 0.85 ] ; P = .007 ) , and a nonsignificant 28 % lower all-cause mortality ( 0.72 [ 0.40 - 1.30 ] ; P = .28 ) than the reference group after adjustment for other outcome -affecting variables . In the CBT group there was a strong dose-response effect between intervention group attendance and outcome . During the first 2 years of follow-up , there were no significant group differences in traditional risk factors . CONCLUSIONS A CBT intervention program decreases the risk of recurrent CVD and recurrent acute myocardial infa rct ion . This may have implication s for secondary preventive programs in patients with coronary heart disease . Trial Registration clinical trials.gov Identifier : NCT00888485 Background Blood Pressure related disease affected 118 million people in India in the year 2000 ; this figure will double by 2025 . Around one in four adults in rural India have hypertension , and of those , only a minority are accessing appropriate care . Health systems in India face substantial challenges to meet these gaps in care , and innovative solutions are needed . Methods We hypothesise that a multifaceted intervention involving capacity strengthening of primary healthcare doctors and non-physician healthcare workers through use of a mobile device-based clinical decision support system will result in improved blood pressure control for individuals at high risk of a cardiovascular disease event when compared with usual healthcare . This intervention will be implemented as a stepped wedge , cluster r and omised controlled trial in 18 primary health centres and 54 villages in rural And hra Pradesh involving adults aged ≥40 years at high cardiovascular disease event risk ( approximately 15,000 people ) . Cardiovascular disease event risk will be calculated based on World Health Organisation/International Society of Hypertension ’s region-specific risk charts . Cluster r and omisation will occur at the level of the primary health centres . Outcome analyses will be conducted blinded to intervention allocation . Expected outcomes The primary study outcome is the difference in the proportion of people meeting guideline -recommended blood pressure targets in the intervention period vs. the control period . Secondary outcomes include mean reduction in blood pressure levels ; change in other cardiovascular disease risk factors , including body mass index , current smoking , reported healthy eating habits , and reported physical activity levels ; self-reported use of blood pressure and other cardiovascular medicines ; quality of life ( using the EQ-5D ) ; and cardiovascular disease events ( using hospitalisation data ) . Trial outcomes will be accompanied by detailed process and economic evaluations . Significance The findings are likely to inform policy on a scalable strategy to overcome entrenched inequities in access to effective healthcare for under-served population s in low and middle income country setting s . Trial registration Clinical Trial Registry India CTRI/2013/06/003753 OBJECTIVE The objective of the present study was to examine the relationship of dietary fried fish consumption and risk of cardiovascular events and all-cause mortality . DESIGN Prospect i ve cohort study among participants of the REasons for Geographic And Racial Differences in Stroke ( REGARDS ) study who resided in the USA . SETTING The primary outcome measures included the hazard ratios ( HR ) of incident CVD including first incident fatal or non-fatal ischaemic stroke or myocardial infa rct ion and all-cause mortality , based on cumulative average fish consumption ascertained at baseline . SUBJECTS Participants ( n 16 479 ) were enrolled between 2003 and 2007 , completed the self-administered Block98 FFQ and were free of CVD at baseline . RESULTS There were 700 cardiovascular events over a mean follow-up of 5·1 years . After adjustment for sociodemographic variables , health behaviours and other CVD risk factors , participants eating ≥2 servings fried fish/week ( v. < 1 serving/month ) were at a significantly increased risk of cardiovascular events ( HR=1·63 ; 95 % CI 1·11 , 2·40 ) . Intake of non-fried fish was not associated with risk of incident CVD . There was no association found with dietary fried or non-fried fish intake and cardiovascular or all-cause mortality . CONCLUSIONS Fried fish intake of two or more servings per week is associated with an increased risk of cardiovascular events . Given the increased intake of fried fish in the stroke belt and among African Americans , these data suggest that dietary fried fish intake may contribute to geographic and racial disparities in CVD IMPORTANCE Sauna bathing is a health habit associated with better hemodynamic function ; however , the association of sauna bathing with cardiovascular and all-cause mortality is not known . OBJECTIVE To investigate the association of frequency and duration of sauna bathing with the risk of sudden cardiac death ( SCD ) , fatal coronary heart disease ( CHD ) , fatal cardiovascular disease ( CVD ) , and all-cause mortality . DESIGN , SETTING , AND PARTICIPANTS We performed a prospect i ve cohort study ( Finnish Kuopio Ischemic Heart Disease Risk Factor Study ) of a population -based sample of 2315 middle-aged ( age range , 42 - 60 years ) men from Eastern Finl and . Baseline examinations were conducted from March 1 , 1984 , through December 31 , 1989 . EXPOSURES Frequency and duration of sauna bathing assessed at baseline . RESULTS During a median follow-up of 20.7 years ( interquartile range , 18.1 - 22.6 years ) , 190 SCDs , 281 fatal CHDs , 407 fatal CVDs , and 929 all-cause mortality events occurred . A total of 601 , 1513 , and 201 participants reported having a sauna bathing session 1 time per week , 2 to 3 times per week , and 4 to 7 times per week , respectively . The numbers ( percentages ) of SCDs were 61 ( 10.1 % ) , 119 ( 7.8 % ) , and 10 ( 5.0 % ) in the 3 groups of the frequency of sauna bathing . The respective numbers were 89 ( 14.9 % ) , 175 ( 11.5 % ) , and 17 ( 8.5 % ) for fatal CHDs ; 134 ( 22.3 % ) , 249 ( 16.4 % ) , and 24 ( 12.0 % ) for fatal CVDs ; and 295 ( 49.1 % ) , 572 ( 37.8 % ) , and 62 ( 30.8 % ) for all-cause mortality events . After adjustment for CVD risk factors , compared with men with 1 sauna bathing session per week , the hazard ratio of SCD was 0.78 ( 95 % CI , 0.57 - 1.07 ) for 2 to 3 sauna bathing sessions per week and 0.37 ( 95 % CI , 0.18 - 0.75 ) for 4 to 7 sauna bathing sessions per week ( P for trend = .005 ) . Similar associations were found with CHD , CVD , and all-cause mortality ( P for trend ≤.005 ) . Compared with men having a sauna bathing session of less than 11 minutes , the adjusted hazard ratio for SCD was 0.93 ( 95 % CI , 0.67 - 1.28 ) for sauna bathing sessions of 11 to 19 minutes and 0.48 ( 95 % CI , 0.31 - 0.75 ) for sessions lasting more than 19 minutes ( P for trend = .002 ) ; significant inverse associations were also observed for fatal CHDs and fatal CVDs ( P for trend ≤.03 ) but not for all-cause mortality events . CONCLUSIONS AND RELEVANCE Increased frequency of sauna bathing is associated with a reduced risk of SCD , CHD , CVD , and all-cause mortality . Further studies are warranted to establish the potential mechanism that links sauna bathing and cardiovascular health Background —In apparently healthy people , the relation between blood pressure and risk of subsequent cardiovascular disease ( CVD ) is linear . In persons with CVD , the relation is uncertain . Methods and Results —We conducted a prospect i ve study of 5218 older women with CVD who reported their blood pressure at baseline in the Women ’s Antioxidant Cardiovascular Study ( WACS ) , an ongoing double-blind , placebo-controlled secondary prevention trial of the benefits and risks of antioxidant vitamins , folic acid , vitamin B6 , and vitamin B12 among women with CVD or ≥3 coronary risk factors . A total of 661 confirmed CVD events ( nonfatal myocardial infa rct ion , nonfatal stroke , coronary artery bypass graft procedure , percutaneous coronary angioplasty , or CVD death ) occurred during a median follow-up of 6.5 years . After controlling for age , r and omized treatment assignment , antihypertensive medication use , and coronary risk factors , we found that systolic blood pressure ( SBP ) was a strong predictor of CVD events and that the relation between SBP and CVD risk was positive , continuous , and linear ( P for linear trend=0.001 ) . For each 10-mm Hg increment in SBP , there was a 9 % ( 95 % CI 4 % to 15 % ) increase in risk of secondary CVD events . Diastolic blood pressure , mean arterial pressure , and pulse pressure were weaker predictors of CVD risk in this cohort , and joint consideration of SBP and diastolic blood pressure found that only SBP significantly predicted risk . Use of antihypertensive medication did not modify the relationship of SBP with CVD events . Conclusions —In this population of women with CVD , we observed a strong , continuous , and linear association between SBP and risk of secondary CVD events . SBP was the blood pressure measure most strongly related to CVD risk OBJECTIVE To measure the costs of a polypill strategy and compare them with those of usual care in people with established cardiovascular disease ( CVD ) or at similarly high cardiovascular risk . DESIGN A within-trial cost analysis of polypill-based care versus usual care with separate medications , using data from the Kanyini Guidelines Adherence with the Polypill ( GAP ) trial and linked health service and medication administrative cl aims data . PARTICIPANTS Kanyini GAP participants who consented to Australian Medicare record access . MAIN OUTCOME MEASURES Mean health service and pharmaceutical expenditure per patient per year , estimated with generalised linear models . Costs during the trial ( r and omisation January 2010 - May 2012 , median follow-up 19 months , maximum follow-up 36 months ) were inflated to 2012 costs . RESULTS Our analysis showed a statistically significantly lower mean pharmaceutical expenditure of $ 989 ( 95 % CI , $ 648-$1331 ) per patient per year in the polypill arm compared with usual care ( P < 0.001 ; adjusted , excluding polypill cost ) . No significant difference was shown in health service expenditure . CONCLUSIONS This study provides evidence of significant cost savings to the taxpayer and Australian Government through the introduction of a CVD polypill strategy . The savings will be less now than during the trial due to subsequent reductions in the costs of usual care . Nonetheless , given the prevalence of CVD in Australia , the introduction of this polypill could increase considerably the efficiency of health care expenditure in Australia . TRIAL REGISTRATION Australian New Zeal and Clinical Trials Registry ACTRN126080005833347 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 Background Cardiac rehabilitation is very important for the recovery and the secondary prevention of cardiovascular disease , and one of its main strategies is to increase the level of physical activity . Internet and mobile phone based interventions have been successfully used to help people to achieve this . One of the components that are related to the efficacy of these interventions is tailoring of content to the individual . This trial is study ing the effect of a longitudinally tailored Internet and mobile phone based intervention that is based on models of health behaviour , on the level of physical activity and the adherence to the intervention , as an extension of a face-to-face cardiac rehabilitation stay . Methods / Design A parallel group , cluster r and omized controlled trial . The study population is adult participants of a cardiac rehabilitation programme in Norway with home Internet access and mobile phone , who in monthly clusters are r and omized to the control or the intervention condition . Participants have access to a website with information regarding cardiac rehabilitation , an online discussion forum and an online activity calendar . Those r and omized to the intervention condition , receive in addition tailored content based on models of health behaviour , through the website and mobile text messages . The objective is to assess the effect of the intervention on maintenance of self-management behaviours after the rehabilitation stay . Main outcome is the level of physical activity one month , three months and one year after the end of the cardiac rehabilitation programme . The r and omization of clusters is based on a true r and om number online service , and participants , investigators and outcome assessor are blinded to the condition of the clusters . Discussion The study suggests a theory-based intervention that combines models of health behaviour in an innovative way , in order to tailor the delivered content . The users have been actively involved in its design , and because of the use of Open- Source software , the intervention can easily and at low-cost be reproduced and exp and ed by others . Challenges are the recruitment in the elderly population and the possible underrepresentation of women in the study sample . Funding by Northern Norway Regional Health Authority . Trial registration Trial registry http://www . clinical trials.gov : NCT01223170 Overweight and obesity are major contributors to both type 2 diabetes and cardiovascular disease ( CVD ) . Moreover , individuals with type 2 diabetes who are overweight or obese are at particularly high risk for CVD morbidity and mortality . Although short-term weight loss has been shown to ameliorate obesity-related metabolic abnormalities and CVD risk factors , the long-term consequences of intentional weight loss in overweight or obese individuals with type 2 diabetes have not been adequately examined . The primary objective of the Look AHEAD clinical trial is to assess the long-term effects ( up to 11.5 years ) of an intensive weight loss program delivered over 4 years in overweight and obese individuals with type 2 diabetes . Approximately 5000 male and female participants who have type 2 diabetes , are 45 - 74 years of age , and have a body mass index > or=25 kg/m(2 ) will be r and omized to one of the two groups . The intensive lifestyle intervention is design ed to achieve and maintain weight loss through decreased caloric intake and increased physical activity . This program is compared to a control condition given diabetes support and education . The primary study outcome is time to incidence of a major CVD event . The study is design ed to provide a 0.90 probability of detecting an 18 % difference in major CVD event rates between the two groups . Other outcomes include components of CVD risk , cost and cost-effectiveness , diabetes control and complications , hospitalizations , intervention processes , and quality of life
While the results of this systematic review are promising , there is insufficient evidence to draw conclusions on the effectiveness of text message-based interventions for adherence to medications for secondary prevention of CVD .
BACKGROUND Worldwide at least 100 million people are thought to have prevalent cardiovascular disease ( CVD ) .
This population has a five times greater chance of suffering a recurrent cardiovascular event than people without known CVD .
Secondary CVD prevention is defined as action aim ed to reduce the probability of recurrence of such events .
Drug interventions have been shown to be cost-effective in reducing this risk and are recommended in international guidelines .
However , adherence to recommended treatments remains sub-optimal .
In order to influence non-adherence , there is a need to develop scalable and cost-effective behaviour-change interventions .
OBJECTIVES To assess the effects of mobile phone text messaging in patients with established arterial occlusive events on adherence to treatment , fatal and non-fatal cardiovascular events , and adverse effects .