Global Risk Assessment to Guide Blood Pressure Management in Cardiovascular Disease Prevention A multifaceted quality improvement intervention for CVD risk management in Australian primary healthcare: a protocol for a process evaluation Secondary prevention of cardiovascular disease: a randomised trial of training in information management, evidence-based medicine, both or neither: the PIER trial. The Treatment of cardiovascular Risk in Primary care using Electronic Decision suppOrt (TORPEDO) study: intervention development and protocol for a cluster randomised, controlled trial of an electronic decision support and quality improvement intervention in Australian primary healthcare The impact of a point-of-care testing device on CVD risk assessment completion in New Zealand primary-care practice: A cluster randomised controlled trial and qualitative investigation Effectiveness of a tailored intervention to improve cardiovascular risk management in primary care: study protocol for a randomised controlled trial The South Asian Heart Lifestyle Intervention (SAHELI) study to improve cardiovascular risk factors in a community setting: design and methods. Improving diabetes care: multi-component cardiovascular disease risk reduction strategies for people with diabetes in South Asia--the CARRS multi-center translation trial. National Study of Physician Awareness and Adherence to Cardiovascular Disease Prevention Guidelines Impact of socioeconomic deprivation on screening for cardiovascular disease risk in a primary prevention population: a cross-sectional study Does training of general practitioners for intensive treatment of people with screen-detected diabetes have a spillover effect on mortality and cardiovascular morbidity in ‘at risk’ individuals with normoglycaemia? Results from the ADDITION-Denmark cluster-randomised controlled trial Cost-Effectiveness of the Diabetes Care Protocol, a Multifaceted Computerized Decision Support Diabetes Management Intervention That Reduces Cardiovascular Risk NHS health checks through general practice: randomised trial of population cardiovascular risk reduction Designing an Internet-Based Multidomain Intervention for the Prevention of Cardiovascular Disease and Cognitive Impairment in Older Adults: The HATICE Trial. Quality of cardiovascular disease preventive care and physician/practice characteristics Effects on cardiovascular disease risk of a web-based health risk assessment with tailored health advice: a follow-up study Cost-effectiveness of interventions to control cardiovascular diseases and type 2 diabetes mellitus in South Asia: protocol for a systematic review The systematic coronary risk evaluation (SCORE) for the prevention of cardiovascular diseases. Does evidence exist for its effectiveness? A systematic review The Effectiveness of Pharmacist Interventions on Cardiovascular Risk: The Multicenter Randomized Controlled RxEACH Trial. Efficacy of a nurse-led email reminder program for cardiovascular prevention risk reduction in hypertensive patients: a randomized controlled trial. Evaluation of cardiovascular risk predicted by different SCORE equations: The Netherlands as an example Lifestyle‐Based Prediction Model for the Prevention of CVD: The Healthy Heart Score Cardiovascular disease risk reduction in rural China: a clustered randomized controlled trial in Zhejiang Clinical trial of an Internet-based case management system for secondary prevention of heart disease. Randomized controlled trial to assess reduction of cardiovascular disease risk in patients with bipolar disorder: the Self-Management Addressing Heart Risk Trial (SMAHRT). Physicians' perception, knowledge and awareness of cardiovascular risk factors and adherence to prevention guidelines: the PERCRO-DOC survey. Cardiovascular Risk Factor Screening Satisfaction in the Heart of New Ulm Project Evaluation of a toolkit to improve cardiovascular disease screening and treatment for people with type 2 diabetes: protocol for a cluster-randomized pragmatic trial Markers of inflammation and cardiovascular disease: application to clinical and public health practice: A statement for healthcare professionals from the Centers for Disease Control and Prevention and the American Heart Association. The effects of Hartcoach, a life style intervention provided by telephone on the reduction of coronary risk factors: a randomised trial An integrated general practice and pharmacy-based intervention to promote the use of appropriate preventive medications among individuals at high cardiovascular disease risk: protocol for a cluster randomized controlled trial Glycated hemoglobin measurement and prediction of cardiovascular disease. Predictive accuracy of the 'Framingham's general CVD algorithm' in a Middle Eastern population: Tehran Lipid and Glucose Study. Prognostic value of depression, anxiety, and anger in hospitalized cardiovascular disease patients for predicting adverse cardiac outcomes. Impact of intensive lifestyle and metformin therapy on cardiovascular disease risk factors in the diabetes prevention program. Does erectile dysfunction contribute to cardiovascular disease risk prediction beyond the Framingham risk score? Cardiovascular disease, risk factors and heart rate variability in the elderly general population: Design and objectives of the CARdiovascular disease, Living and Ageing in Halle (CARLA) Study Care manager to control cardiovascular risk factors in primary care: the Raffaello cluster randomized trial. Cardiorespiratory Fitness in Childhood and Adolescence Affects Future Cardiovascular Risk Factors: A Systematic Review of Longitudinal Studies Use of community-based participatory research to disseminate baseline results from a cardiovascular disease randomized community trial for Mexican Americans living in a U.S.-Mexico border community. Relationship between low cardiorespiratory fitness and mortality in normal-weight, overweight, and obese men. Increasing knowledge of cardiovascular risk factors among African Americans by use of community health workers: the ABCD community intervention pilot project. Sex Disparities in Control and Treatment of Modifiable Cardiovascular Disease Risk Factors Among Patients With Diabetes Snoring and risk of cardiovascular disease in women. Cardiovascular risk factors and confounders among nondrinking and moderate-drinking U.S. adults. Effectiveness and cost-effectiveness of a telehealth intervention to support the management of long-term conditions: study protocol for two linked randomized controlled trials Impact of a nurse-led intervention to improve screening for cardiovascular risk factors in people with severe mental illnesses. Phase-two cluster randomised feasibility trial of community mental health teams Multifactor cardiovascular disease risk reduction in medically underserved, high-risk patients. Sun, vitamin D, and cardiovascular disease. Do clinicians prescribe exercise similarly in patients with different cardiovascular diseases? Findings from the EAPC EXPERT working group survey A prospective study of dietary fiber intake and risk of cardiovascular disease among women.
Elevated blood pressure ( BP ) is a causal risk factor for cardiovascular disease ( CVD ) . Epidemiological analyses have established the grade d and continuous association between higher BP and CVD . Moreover , r and omized clinical trials among individuals with hypertension have demonstrated , in aggregate , a reduction in CVD events by 20 % , coronary heart disease ( CHD ) by 17 % , stroke by 27 % , and heart failure by 28 % for every 10 mm Hg systolic BP ( SBP ) lowering with medical therapy.1 Therefore , prevention , detection , treatment , and control of elevated BP , and its clinical correlate hypertension , is an important public health priority and a primary target for CVD prevention . Although national health surveys have demonstrated improvements in hypertension awareness and treatment , strategic opportunities to improve the efficiency and efficacy of applying BP-lowering therapy in patients most likely to benefit remain.2 Global CVD risk assessment , using multivariable prediction models that estimate absolute CVD risk from routinely measured clinical variables , has been promulgated in several CVD prevention guidelines for cholesterol management to target the most intensive preventive therapies to those at highest absolute CVD risk.3–5 Hypertension guidelines , however , have instead relied solely on isolated BP thresholds and BP goals to guide treatment initiation and intensity . In this review , we provide a rationale for incorporating global CVD risk assessment in BP treatment decision-making and propose a framework to guide its implementation in future CVD prevention guidelines . Epidemiological analyses have firmly established that CVD is a multifactorial condition and that modest increases of several CVD risk factors can often lead to greater overall risk than a severe elevation of a Background Cardiovascular disease ( CVD ) is the leading cause of death and disability worldwide . Despite the widespread availability of evidence -based clinical guidelines and vali date d risk predication equations for prevention and management of CVD , their translation into routine practice is limited . We developed a multifaceted quality improvement intervention for CVD risk management which incorporates electronic decision support , patient risk communication tools , computerised audit and feedback tools , and monthly , peer-ranked performance feedback via a web portal . The intervention was implemented in a cluster r and omised controlled trial in 60 primary healthcare services in Australia . Overall , there were improvements in risk factor recording and in prescribing of recommended treatments among under-treated individuals , but it is unclear how this intervention was used in practice and what factors promoted or hindered its use . This information is necessary to optimise intervention impact and maximally implement it in a post-trial context . In this study protocol , we outline our methods to conduct a theory-based , process evaluation of the intervention . Our aims are to underst and how , why , and for whom the intervention produced the observed outcomes and to develop effective strategies for translation and dissemination . Methods / Design We will conduct four discrete but inter-related studies taking a mixed methods approach . Our quantitative studies will examine ( 1 ) the longer term effectiveness of the intervention post-trial , ( 2 ) patient and health service level correlates with trial outcomes , and ( 3 ) the health economic impact of implementing the intervention at scale . The qualitative studies will ( 1 ) identify healthcare provider perspectives on implementation barriers and enablers and ( 2 ) use video ethnography and patient semi-structured interviews to underst and how cardiovascular risk is communicated in the doctor/patient interaction both with and without the use of intervention . We will also assess the costs of implementing the intervention in Australian primary healthcare setting s which will inform scale-up considerations . Discussion This mixed methods evaluation will provide a detailed underst and ing of the process of implementing a  quality improvement intervention and identify the factors that might influence scalability and sustainability . Trials registration 12611000478910 BACKGROUND Sub-optimal management of cardiovascular disease ( CVD ) patients is widespread in primary and secondary care , with risk factors frequently unrecorded or untreated . AIM To investigate the effectiveness of educational interventions developed in primary care , on recording , prescribing and control of risk factors among all patients recorded by their general practitioner as having CVD . DESIGN OF STUDY Factorial , duster-r and omised controlled trial . SETTING Primary care teams representing the range of practice development in a geographically defined area in inner London . METHOD Participating practice s were r and omly allocated to one of the four intervention groups : information , evidence , both or neither . Interventions were tailored to suit individual practice needs . At a mean of 19 months after baseline , and three months after the end of intervention , practice s carried out the follow-up assessment of recording , treatment , and control of risk factors in the same CVD patients . RESULTS Adequate recording of all three risk factors , found inapproximately a third of patients at baseline , increased non-significantly by 10.5 % ( 95 % confidence interval [ CI ] = 3.9 to 24.9 ) in the information ( versus not information ) group and by 6.6 % ( 95 % [ CI ] = 8.9 to 22.0 ) in the evidence ( versus not evidence ) group . Factorial improvements in prescribing and control of risk factors tended not to be significant . Adequate recording of an three risk factors showed the greatest improvement in the information plus evidence group ( 19.9 % increase , P for heterogeneity across the four groups < or = 0.001 ) . Mean change from baseline to follow-up within the four intervention groups suggested improvements in the combined information plus evidence group in cholesterol recording ( 22.5 % increase ) , prescribing of lipid lowering drugs ( 4.4 % increase ) and mean cholesterol ( 0.7 mmol/l decrease ) . CONCLUSIONS Adequate risk factor recording did not differ between the information ( versus not information ) or the evidence ( versus not evidence ) intervention groups . Combined training in information systems and evidence -based medicine should be considered in the design of future interventions , to improve secondary prevention of CVD Background Large gaps exist in the implementation of guideline recommendations for cardiovascular disease ( CVD ) risk management .  Electronic decision support ( EDS ) systems are promising interventions to close these gaps but few have undergone clinical trial evaluation in Australia . We have developed HealthTracker , a multifaceted EDS and quality improvement intervention to improve the management of CVD risk . Methods / design It is hypothesised that the use of HealthTracker over a 12-month period will result in : ( 1 ) an increased proportion of patients receiving guideline -indicated measurements of CVD risk factors and ( 2 ) an increased proportion of patients at high risk will receive guideline -indicated prescriptions for lowering their CVD risk . Sixty health services ( 40 general practice s and 20 Aboriginal Community Controlled Health Services ( ACCHSs ) will be r and omised in a 1:1 allocation to receive either the intervention package or continue with usual care , stratified by service type , size and participation in existing quality improvement initiatives . The intervention consists of point-of-care decision support ; a risk communication interface ; a clinical audit tool to assess performance on CVD-related indicators ; a quality improvement component comprising peer-ranked data feedback and support to develop strategies to improve performance .  The control arm will continue with usual care without access to these intervention components . Quantitative data will be derived from cross-sectional sample s at baseline and end of study via automated data extraction . Detailed process and economic evaluations will also be conducted . Ethics and dissemination The general practice component of the study is approved by the University of Sydney Human Research Ethics Committee ( HREC ) and the ACCHS component is approved by the Aboriginal Health and Medical Research Council HREC . Formal agreements with each of the participating sites have been signed . In addition to the usual scientific forums , results will be disseminated via newsletters , study websites , face-to-face feedback forums and workshops . Trial registration The trial is registered with the Australian Clinical Trials Registry ACTRN 12611000478910 Objectives To assess the effect of a point of care ( POC ) device for testing lipids  and HbA1c in addition to testing by community laboratory facilities ( usual practice ) on the completion of cardiovascular disease ( CVD ) risk assessment s in general practice . Methods We conducted a pragmatic , cluster r and omised controlled trial in 20 New Zeal and general practice s stratified by size and rurality and r and omised to POC device plus usual practice or usual practice alone ( controls ) . Patients aged 35–79 years were eligible if they met national guideline criteria for CVD risk assessment . Data on CVD risk assessment s were aggregated using a web-based decision support programme common to each practice . Data entered into the on-line CVD risk assessment form could be saved pending blood test results . The primary outcome was the proportion of completed CVD risk assessment s. Qualitative data on practice processes for CVD risk assessment and feasibility of POC testing were collected at the end of the study by interviews and question naire . The POC testing was supported by a comprehensive quality assurance programme . Results A CVD risk assessment entry was recorded for 7421 patients in 10 POC practice s and 6217 patients in 10 control practice s ; 99.5 % of CVD risk assessment s had complete data in both groups ( adjusted odds ratio 1.02 [ 95%CI 0.61–1.69 ] ) . There were major external influences that affected the trial : including a national performance target for CVD risk assessment and changes to CVD guidelines . All practice s had invested in systems and dedicated staff time to identify and follow up patients to completion . However , the POC device was viewed by most as an additional tool rather than as an opportunity to review practice work flow and leverage the immediate test results for patient education and CVD risk management discussion s. Shortly after commencement , the trial was halted due to a change in the HbA1c test assay performance . The trial restarted after the manufacturing issue was rectified but this affected the end use of the device . Conclusions Performance incentives and external influences were more powerful modifiers of practice behaviours than the POC device in relation to CVD risk assessment completion . The promise of combining risk assessment , communication and management within one consultation was not realised . With shifts in policy focus , the utility of POC devices for patient engagement in CVD preventive care may be demonstrated if fully integrated into the clinical setting . Trial registration Australian New Zeal and Clinical Trials Registry Abstract Background Cardiovascular disease ( CVD ) is an important worldwide cause of mortality . In The Netherl and s , CVD is the leading cause of death for women and the second cause of death for men . Recommendations for diagnosis and treatment of CVD are not well implemented in primary care . In this study , we aim to examine the effectiveness of a tailored implementation program targeted at practice nurses to improve healthcare for patients with ( high risk for ) CVD . Methods / design A two-arm cluster r and omized trial is planned . We offer practice nurses a tailored program to improve adherence to six specific recommendations related to blood pressure and cholesterol target values , risk profiling and lifestyle advice . Practice nurses are offered training and feedback on their motivational interviewing technique and an e-learning program on cardiovascular risk management ( CVRM ) . They are also advised to screen for the presence and severity of depressive symptoms in patients . We also advise practice nurses to use selected E-health options ( selected websites and Twitter-consult ) in patients without symptoms of depression . Patients with mild depressive symptoms are referred to a physical exercise group . We recommend referring patients with major depressive symptoms for assessment and treatment of depressive symptoms if appropriate before starting CVRM .  Data from 900 patients at high risk of CVD or with established CVD will be collected in 30 general practice s in several geographical areas in The Netherl and s. The primary outcome measure is performance of practice nurses in CVRM and reflects application of recommendations for personalized counselling and education of CVRM patients . Patients ’ health-related lifestyles ( physical exercise , diet and smoking status ) will be measured with vali date d question naires and medical record audit will be performed to document estimated CVD risk . Additionally , we will survey and interview participating healthcare professionals for exploration of processes of change . The control practice s will provide usual care . Discussion Tailored interventions can improve healthcare . An underst and ing of the methods to reach the improved healthcare can be improved . This research contributes a share of it . Identification of the determinants of practice and developing implementation interventions were two steps which were completed . The subsequent step was implementation of the tailored intervention program . Trial registration Name trial register : Nederl and s trial registerWeb address of trial register : http://www.trialregister.nl Data of registration : 11 July 2013Number of registration : Disseminating and implementing evidence -based , cardiovascular disease ( CVD ) prevention lifestyle interventions in community setting s and in ethnic minority population s is a challenge . We describe the design and methods for the South Asian Heart Lifestyle Intervention ( SAHELI ) study , a pilot study design ed to determine the feasibility and initial efficacy of a culturally-targeted , community-based lifestyle intervention to improve physical activity and diet behaviors among medically underserved South Asians ( SAs ) . Participants with at least one CVD risk factor will be r and omized to either a lifestyle intervention or a control group .  Participants in both groups will be screened in a community setting and receive a primary care referral after r and omization . Intervention participants will receive 6weeks of group classes , followed by 12weeks of individual telephone support where they will be encouraged to initiate and maintain a healthy lifestyle goal . Control participants will receive their screening results and monthly mailings on CVD prevention . Primary outcomes will be changes in moderate/vigorous physical activity and saturated fat intake between baseline , 3- , and 6-month follow-up . Secondary outcomes will be changes in weight , clinical risk factors , primary care visits , self-efficacy , and social support . This study will be one of the first to pilot-test a lifestyle intervention for SAs , one of the fastest growing racial/ethnic groups in the U.S. and one with disparate CVD risk . Results of this pilot study will provide preliminary data about the efficacy of a lifestyle intervention on CVD risk in SAs and inform community-engaged CVD prevention efforts in an increasingly diverse U.S. population AIMS Cardiovascular disease ( CVD ) is the leading cause of morbidity and mortality in people with diabetes in South Asia . The CARRS Translation Trial tests the effectiveness , cost-effectiveness , and sustainability of a clinic-based multi-component CVD risk reduction intervention among people with diabetes in India and Pakistan . METHODS We r and omly assigned 1146 adults with diabetes recruited from 10 urban clinic sites , to receive usual care by physicians or to receive an integrated multi-component CVD risk reduction intervention . The intervention involves electronic health record management , decision-support prompts to the healthcare team , and the support of a care coordinator to actively facilitate patient and provider adherence to evidence -based guidelines . The primary outcome is a composite of multiple CVD risk factor control ( blood glucose and either blood pressure or cholesterol , or all three ) . Other outcomes include control of the individual CVD risk factors , process and patient-centered measures , cost-effectiveness , and acceptability/feasibility . CONCLUSION The CARRS Translation Trial tests a low-cost diabetes care delivery model in urban South Asia to achieve comprehensive cardio-metabolic disease case-management of high-risk patients ( clinical trials.gov number : NCT01212328 ) 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 Investigate the association between socioeconomic deprivation and completeness of cardiovascular disease ( CVD ) risk factor recording in primary care , uptake of screening in people with incomplete risk factor recording and with actual CVD risk within the screened subgroup . Design Cross-sectional study . Setting Nine UK general practice s. Participants 7987 people aged 50–74 years with no CVD diagnosis . Methods CVD risk was estimated using the Framingham equation from data extracted from primary care electronic health records . Where there was insufficient information to calculate risk , patients were invited to attend a screening assessment . Analysis Proportion of patients for whom clinical data were sufficiently complete to enable CVD risk to be calculated ; proportion of patients invited to screening who attended ; proportion of patients who attended screening whose 10-year risk of a cardiovascular event was high ( > 20 % ) . For each outcome , a set of logistic regression models were run . Crude and adjusted ORs were estimated for person-level deprivation , age , gender and smoking status . We included practice -level deprivation as a continuous variable and practice as a r and om effect to account for clustering . Results People who had lower  Indices of Multiple Deprivation ( IMD ) scores ( less deprived ) had significantly worse routine CVD risk factor recording ( adjusted OR 0.97 ( 0.95 to 1.00 ) per IMD decile ; p=0.042 ) . Screening attendance was poorer in those with more deprivation ( adjusted OR 0.89 ( 0.86 to 0.91 ) per IMD decile ; p<0.001 ) . Among those who attended screening , the most deprived were more likely to have CVD risk > 20 % ( OR 1.09 ( 1.03 to 1.15 ) per IMD decile ; p=0.004 ) . Conclusions Our data suggest that those who had the most to gain from screening were least likely to attend , potentially exacerbating existing health inequalities . Future research should focus on tailoring the delivery of CVD screening to ensure engagement of socioeconomically deprived groups Aims /hypothesisWithin a trial of intensive treatment of people with screen-detected diabetes , we aim ed to assess a potential spillover effect of the trial intervention on incident cardiovascular disease ( CVD ) and all-cause mortality among people who screened positive on a diabetes risk question naire but who were normoglycaemic . Methods In the Anglo – Danish – Dutch Study of Intensive Treatment In People with Screen-Detected Diabetes in Primary Care (ADDITION)-Denmark trial , 175 general practice s were cluster-r and omised into : ( 1 ) screening plus routine care of individuals with screen-detected diabetes ( control group ) ;  or (  2 ) screening plus training and support in intensive multifactorial treatment of individuals with screen-detected diabetes ( intervention  group  ) . We identified all individuals who screened positive on a diabetes risk question naire in ADDITION-Denmark but were normoglycaemic following biochemical testing for use in this secondary analysis . After a median 8.9 years follow-up , we used data from national registers to compare rates of first CVD events and all-cause mortality in individuals in the routine care group with those in the intensive treatment group . Results In total , 21,513 individuals screened positive for high risk of diabetes but were normoglycaemic on biochemical testing in ADDITION-Denmark practice s between 2001 and 2006 ( 10,289 in the routine care group and 11,224 in the intensive treatment group ) . During 9 years of follow-up , there were 3784 first CVD events and 1748 deaths . The incidence of CVD was lower among the intensive treatment group compared with the routine care group ( HR 0.92 [ 95 % CI 0.85 , 0.99 ] ) . This association was stronger among individuals at highest CVD risk ( heart SCORE ≥ 10 ; HR 0.85 [ 95 % CI 0.75 , 0.96 ] ) . There was no difference in mortality between the two treatment groups ( HR 1.02 [ 95 % CI 0.92 , 1.14 ] ) . Conclusions /interpretationTraining of general practitioners to provide target-driven intensive management of blood glucose levels and other cardiovascular risk factors showed some evidence of a spillover effect on the risk of CVD over a 9 year period among individuals at high risk of diabetes . The effect was particularly pronounced among those at highest risk of CVD . There was no effect on mortality . Trial registration : Clinical Trials.gov OBJECTIVE The Diabetes Care Protocol ( DCP ) , a multifaceted computerized decision support diabetes management intervention , reduces cardiovascular risk of type 2 diabetic patients . We performed a cost-effectiveness analysis of DCP from a Dutch health care perspective . RESEARCH DESIGN AND METHODS A cluster r and omized trial provided data of DCP versus usual care . The 1-year follow-up patient data were extrapolated using a modified Dutch microsimulation diabetes model , computing individual lifetime health-related costs , and health effects . Incremental costs and effectiveness ( quality -adjusted life-years [ QALYs ] ) were estimated using multivariate generalized estimating equations to correct for practice -level clustering and confounding . Incremental cost-effectiveness ratios ( ICERs ) were calculated and cost-effectiveness acceptability curves were created . Stroke costs were calculated separately . Subgroup analyses examined patients with and without cardiovascular disease ( CVD+ or CVD− patients , respectively ) . RESULTS Excluding stroke  , DCP patients lived longer ( 0.14 life-years , P = NS ) , experienced more QALYs ( 0.037 , P = NS ) , and incurred higher total costs ( € 1,415 , P = NS ) , result ing in an ICER of € 38,243 per QALY gained . The likelihood of cost-effectiveness given a willingness-to-pay threshold of € 20,000 per QALY gained is 30 % . DCP had a more favorable effect on CVD+ patients ( ICER = € 14,814 ) than for CVD− patients ( ICER = € 121,285 ) . Coronary heart disease costs were reduced ( € −587 , P < 0.05 ) . CONCLUSIONS DCP  reduces cardiovascular risk , result ing in only a slight improvement in QALYs , lower CVD costs , but higher total costs , with a high cost-effectiveness ratio . Cost-effective care can be achieved by focusing on cardiovascular risk factors in type 2 diabetic patients with a history of CVD Background The global burden of the major vascular diseases is projected to rise and to remain the dominant non-communicable disease cluster well into the twenty first century . The Department of Health in Engl and has developed the NHS Health Check service as a policy initiative to reduce population vascular disease risk . The aims of this study were to monitor population changes in cardiovascular disease ( CVD ) risk factors over the first year of the new service and to assess the value of tailored lifestyle support , including motivational interview with ongoing support and referral to other services . Methods R and omised trial comparing NHS Health Check service only with NHS Health Check service plus additional lifestyle support in Stoke on Trent , Engl and . Thirty eight general practice s and 601 ( 365 usual care , 236 additional lifestyle support ) patients were recruited and r and omised independently between September 2009 and February 2010 . Changes in population CVD risk between baseline and one year follow-up were compared , using intention-to-treat analysis . The primary outcome was the Framingham 10 year CVD risk score . Secondary outcomes included individual modifiable risk measures and prevalence of individual risk categories . Additional lifestyle support included referral to a lifestyle coach and free sessions as needed for : weight management , physical activity , cook and eat and positive thinking . Results Average population CVD risk decreased from 32.9 % to 29.4 % ( p < 0.001 ) in the NHS Health Check only group and from 31.9 % to 29.2 % ( p < 0.001 ) in the NHS Health Check plus additional lifestyle support group . There was no significant difference between the two groups at either measurement point . Prevalence of high blood pressure , high cholesterol and smoking were reduced significantly ( p < 0.01 ) in both groups . Prevalence of central obesity was reduced significantly ( p < 0.01 ) in the group receiving additional lifestyle support but not in the NHS Health Check only group . Conclusions The NHS Health Check service in Stoke on Trent result ed in significant reduction in estimated population CVD risk . There was no evidence of further benefit of the additional lifestyle support services in terms of absolute CVD risk reduction BACKGROUND Many dementia and cardiovascular disease ( CVD ) cases in older adults are attributable to modifiable vascular and lifestyle-related risk factors , providing opportunities for prevention . In the Healthy Aging Through Internet Counselling in the Elderly ( HATICE ) r and omized controlled trial , an internet-based multidomain intervention is being tested to improve the cardiovascular risk ( CVR ) profile of older adults . OBJECTIVE To design a multidomain intervention to improve CVR  , based on the guidelines for CVR management , and administered through a coach-supported , interactive , platform to over 2500 community-dwellers aged 65 + in three European countries . METHODS A comparative analysis of national and European guidelines for primary and secondary CVD prevention was performed . Results were used to define the content of the intervention . RESULTS The intervention design focused on promoting awareness and self-management of hypertension , dyslipidemia , diabetes mellitus , and overweight , and supporting smoking cessation , physical activity , and healthy diet . Overall , available guidelines lacked specific recommendations for CVR management in older adults . The comparative analysis of the guidelines showed general consistency for lifestyle-related recommendations . Key differences , identified mostly in methods used to assess the overall CVR , did not hamper the intervention design . Minor country-specific adaptations were implemented to maximize the intervention feasibility in each country . CONCLUSION Despite differences in CVR management within the countries considered , it was possible to design and implement the HATICE multidomain intervention . The study can help define preventative strategies for dementia and CVD that are applicable internationally Abstract BACKGROUND : Quality of cardiovascular disease ( CVD ) preventive care is suboptimal . Recent data correlated increasing years in practice for physicians with lower- quality health care . OBJECTIVE : The purpose of this study was to assess physician awareness/adherence to national blood pressure , cholesterol , and CVD prevention guidelines for women according to physician/ practice characteristics . DESIGN : St and ardized online survey and experimental case studies were administered to 500 r and omly selected U.S. physicians . Multivariable regression models tested physician age , gender , specialty , and practice type as independent predictors of guideline awareness/adherence . RESULTS : Compared with older physicians ( 50 + years ) , younger physicians ( < 50 years ) reported a lower level of awareness of cholesterol guidelines ( P=.04 ) and lower incorporation of women ’s guidelines ( P=.02 ) . Yet , older physicians were less likely to recommend weight management for high-risk cases ( P=.03 ) and less confident in helping patients manage weight ( P=.045 ) than younger physicians . Older physicians were also less likely to identify a low-density lipoprotein < 100 mg/dL as optimal versus younger physicians ( P=.01 ) , as were solo versus nonsolo practitioners ( P=.02 ) . Solo practitioners were less aware of cholesterol guidelines ( P=.04 ) and were more likely to prescribe aspirin  for low-risk female patients than nonsolo practitioners ( P<.01 ) . Solo practitioners rated their clinical judgment as more effective than guidelines in improving patient health outcomes ( P<.01 ) and more frequently rated the patient as the greatest barrier to CVD prevention versus nonsolo practitioners ( P<.01 ) . CONCLUSIONS : Though guideline awareness is high , efforts to promote their utilization are needed and may improve quality outcomes . Targeted education and support for CVD prevention may be helpful to older and solo physicians Introduction : A large proportion of the cardiovascular disease ( CVD ) burden can potentially be prevented by primary prevention programs addressing major causal risk factors . A Web-based health risk assessment ( HRA ) with tailored feedback for individual health promotion is a promising strategy . We evaluated the effect on CVD risk of such a program among employees of a Dutch worksite . Methods : We conducted a prospect i ve follow-up study among 368 employees who voluntarily participated in a Web-based HRA program at a single Dutch worksite in 2008 . The program included a multicomponent HRA through a Web-based electronic question naire , biometrics , and laboratory evaluation . The results were combined with health behavior change theory to generate tailored motivational and educational health advice . On request , a health counseling session with the program physician was available . Follow-up data on CVD risk were collected 1 year after initial participation . The primary outcome was a change in Framingham CVD risk at 6 months relative to baseline . We checked for a possible background effect of an increased health consciousness as a consequence of program introduction at the worksite by comparing baseline measurements of early program participants with baseline measurements of participants who completed the program 6 months later . Results : A total of 176 employees completed follow-up measurements after a mean of 7 months . There was a grade d relation between CVD risk changes and baseline risk , with a relative reduction of 17.9 % ( P = 0.001 ) in the high-risk category ( baseline CVD risk ≥20 % ) . Changes were not explained by additional health counseling , medication , or an increase in health consciousness within the company . Conclusions : Voluntary participation in a Web-based HRA with tailored feedback at the worksite reduced CVD risk by nearly 18 % among participants at high CVD risk and by nearly 5 % among all participants . Web-based HRA could improve CVD risk in similar population s. Future research should focus on the persistence of the effects underlying the CVD risk reduction Introduction While a number of strategies are being implemented to control cardiovascular diseases ( CVDs ) and type 2 diabetes mellitus ( T2DM ) , the cost-effectiveness of these in the South Asian context has not been systematic ally evaluated . We aim to systematic ally review the economic ( cost-effectiveness ) evidence available on the individual- , group- and population -level interventions for control of CVD and T2DM in South Asia . Methods and analysis This review will consider all relevant economic evaluations , either conducted alongside r and omised controlled trials or based on decision modelling estimates . These studies must include participants at risk of developing CVD/T2DM or with established disease in one or more of the South Asian countries ( India , Bangladesh , Pakistan , Sri Lanka , Nepal , Maldives , Bhutan and Afghanistan ) . We will identify relevant papers by systematic ally search ing all major data bases and registries . Selected articles will be screened by two independent research ers . Method ological quality of the studies will be assessed using a modified Drummond and a Phillips checklist . Cochrane guidelines will be followed for bias assessment in the effectiveness studies . Results Results will be presented in line with the PRISMA ( Preferred Reporting Items for Systematic review and Meta- analysis ) checklist , and overall quality of evidence will be presented as per the GRADE ( Grade s of Recommendation , Assessment , Development and Evaluation ) approach . Ethics and dissemination The study has received ethics approval from the All India Institute of Medical Sciences , New Delhi , India . The results of this review will provide policy-relevant recommendations for the uptake of cost-effectiveness evidence in prioritising decisions on essential chronic disease care packages for South Asia . Study registration number PROSPERO CRD42013006479 Objectives : The SCORE model predicts the ten-year risk of cardiovascular mortality but it is still unknown whether applying the SCORE in clinical practice subsequently improves cardiovascular disease ( CVD ) outcomes . The objective of this study is to assess the effect of total cardiovascular risk estimation using the SCORE in preventing serious cardiovascular events in European adults without prior CVD . Methods and results : Data sources : eight bibliographical data bases ( 2003 – August 2015 ) , other internet sources and reference lists of articles were checked . This was supplemented by contact with the board members of the European Society of Cardiology ( ESC ) and the authors of the SCORE model . Study eligibility criteria : all prospect i ve studies in any language investigating the effect of using the SCORE on the clinical outcome ( CVD death , major events and adverse outcomes ) in an adult population were examined . Two review ers assessed the studies independently ( titles , abstract s , full texts ) . After removal of duplicates , 5,256 records were screened and 14 full text papers considered . No eligible studies were identified . An extensive literature search revealed no r and omized control trial or other prospect i ve study comparing significant clinical outcomes between groups that used the SCORE and those who did not . Conclusions : The effect of using the SCORE ( with or without subsequent intervention ) on CVD death , all-cause mortality , major CVD events like myocardial infa rct ion and stroke , as well as adverse outcomes , is still unknown . A cluster r and omised controlled trial is warranted to evaluate the use of the SCORE on important outcomes BACKGROUND Despite the cardiovascular disease ( CVD ) risk associated with hypertension , diabetes , dyslipidemia , and smoking , these risk factors remain poorly identified and controlled . OBJECTIVES The study sought to evaluate the effectiveness of a community pharmacy-based case finding and intervention on cardiovascular risk . METHODS The RxEACH ( Alberta Vascular Risk Reduction Community Pharmacy Project ) study was a r and omized trial conducted in 56 community pharmacies . Participants were recruited by their pharmacist , who enrolled adults at high risk for CVD . Patients were r and omized to usual care ( usual pharmacist care with no specific intervention ) or intervention , comprising a Medication Therapy Management review from their pharmacist and CVD risk assessment and education . Pharmacists prescribed medications and ordered laboratory tests as per their scope of practice to achieve treatment targets . Subjects received monthly follow-up visits for 3 months . The primary outcome was difference in change in estimated CVD risk between groups at 3 months . CVD risk was estimated using the greater of the Framingham , International , or United Kingdom Prospect i ve Diabetes Study risk scores . RESULTS We enrolled 723 patients ( mean 62 years of age ; 58 % male , and 27 % smokers ) . After adjusting for baseline values and center effect , there was a 21 % difference in change in risk for CVD events ( p < 0.001 ) between the intervention and usual care groups . The intervention group had greater improvements in low-density lipoprotein cholesterol ( -0.2 mmol/l ; p < 0.001 ) , systolic blood pressure ( -9.37 mm Hg ; p < 0.001 ) , glycosylated hemoglobin ( -0.92 % ; p < 0.001 ) , and smoking cessation ( 20.2 % ; p = 0.002 ) . CONCLUSIONS The RxEACH study was the first large r and omized trial of CVD risk reduction by community pharmacists , demonstrating a significant reduction in risk for CVD events . Engagement of community pharmacists with an exp and ed scope of practice could have significant public health implication s. ( The Alberta Vascular Risk Reduction Community Pharmacy Project : RxEACH [ RxEACH ] ; NCT01979471 ) BACKGROUND Many strategies have been evaluated to improve the prevention and control of cardiovascular ( CVD ) risk factors . Nursing telephonic and tele-counseling individualized lifestyle educational programs have been found to improve blood pressure control and adherence to lifestyle recommendation . This study tested the efficacy of a nurse-led reminder program through email ( NRP-e ) to improve CVD risk factors among hypertensive adults . METHODS All participants received usual CVD prevention and a guideline -based educational program . Subjects in the NRP-e group also received weekly email alerts and phone calls from a nurse care manager for 6 months . Emails contained a reminder program on the need for adherence with a healthy lifestyle based upon current guidelines . Follow-up visits were scheduled at 1 , 3 and 6 months after enrollment ; r and omization was made central ly and blood sample s were evaluated into a single laboratory . RESULTS The final sample consisted of 98 ( control ) and 100 ( NRP-e ) subjects ( mean age 59.0 ± 14.5 years ; 51.0 % males ) . After 6 months , the following CVD risk factors significantly improved in both groups : body mass index , alcohol and fruit consumption , cigarette smoking , adherence to therapy hours , systolic and diastolic blood pressure , fasting blood glucose , low-density lipoproteins ( LDL ) and total cholesterol , triglycerides , and physical activity . In the NRP-e group , however , the prevalence of several behaviors or conditions at risk decreased significantly more than in the control group : obesity ( -16 % ) , low fruit consumption ( -24 % ) , uncontrolled hypertension ( -61 % ) , LDL ( -56 % ) , and total cholesterol ( -40 % ) . CONCLUSIONS The NRP-e improved a range of CVD risk factors . The program had low costs , required only an average of < 20 min per day in addition to normal practice , and may deserve further evaluation for the inclusion among existing care management approaches Background In Europe , for primary prevention of cardiovascular diseases ( CVD ) , the Systematic COronary Risk Evaluation ( SCORE ) risk charts for high-risk and low-risk regions ( SCORE-high and SCORE-low , respectively ) are used . For the Dutch ‘ Clinical Practice Guideline for Cardiovascular Risk Management ’ an adapted SCORE risk chart ( SCORE-NL ) was developed in collaboration with the SCORE group . We evaluated these three SCORE equations using Dutch risk factor and mortality data . Design Prospect i ve cohort study with 10-year follow-up . Methods Baseline data were collected between 1987 and 1997 in 32 885 persons aged 37.5–62.5 years .  Vital status was checked and causes of death were obtained from Statistics Netherl and s. On the basis of the level of risk factors , the expected number of CVD deaths was calculated by applying the three SCORE equations and compared with the observed number . Results The observed CVD mortality was three-fold higher in men ( n = 242 ; 1.6 % ) than in women ( n = 83 ; 0.5 % ) . On the basis of SCORE-NL , 8.5 % of the men and 0.8 % of the women had a CVD mortality risk of 5 % or more . The ratio of the observed-to-expected number of CVD deaths was 0.75 for men and 0.55 for women using SCORE-NL , 0.54 and 0.56 using SCORE-high , and 1.11 and 0.95 using SCORE-low . Conclusion At the population level , SCORE-low predicts the number of CVD deaths well , whereas both SCORE-NL and SCORE-high overestimate the number of CVD deaths by a factor 1.5–2 Background Clinical practice focuses on the primary prevention of  cardiovascular ( CV ) disease ( CVD ) through the modification and pharmacological treatment of elevated risk factors . Prediction models based on established risk factors are available for use in the primary prevention setting . However , the prevention of risk factor development through healthy lifestyle behaviors , or primordial prevention , is of paramount importance to achieve optimal population ‐wide CV health and minimize long‐term CVD risk . Methods and Results We developed a  lifestyle‐based CVD prediction model among 61 025 women in the Nurses ’ Health Study and 34 478 men in the Health Professionals Follow‐up Study , who were free of chronic disease in 1986 and followed for ≤24 years .  Lifestyle factors  were assessed by question naires in 1986 . In the derivation step , we used the Bayes Information Criterion to create parsimonious 20‐year risk prediction models among a r and om two thirds of participants in each cohort separately . The scores were vali date d in the remaining one third of participants in each cohort . Over 24 years , there were 3775 cases of CVD in women and 3506 cases in men . The Healthy Heart Score included age , smoking , body mass index , exercise , alcohol , and a composite diet score . In the validation cohort , the risk score demonstrated good discrimination ( Harrell 's C‐index , 0.72 ; 95 % confidence interval [ CI ] , 0.71 , 0.74 [ women ] ; 0.77 ; 95 % CI , 0.76 , 0.79 [ men ] ) , fit , and calibration , particularly among individuals without baseline hypertension or hypercholesterolemia . Conclusions The Healthy Heart Score accurately identifies individuals at elevated risk for CVD and may serve as an important clinical and public health screening tool for the primordial prevention of CVD Background Cardiovascular disease ( CVD ) 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 PURPOSE Despite demonstrated benefits of cardiac rehabilitation and risk factor reduction , only 11 % to 38 % of eligible patients with cardiovascular disease ( CVD ) participate in cardiac rehabilitation programs .  Women and older adults are particularly less likely to participate in cardiac rehabilitation . In an effort to broaden access to cardiac rehabilitation , the authors developed an alternative Internet-based program that allows nurse case managers to provide risk factor management training , risk factor education , and monitoring services to patients with CVD . METHODS The evaluation consisted of a r and omized , clinical trial involving 104 patients with CVD , 53 of whom used the program as a special intervention ( SI ) for 6 months and 51 of whom received usual care ( UC ) .  RESULTS The results indicate that fewer cardiovascular events occurred among the SI subjects ( 15.7 % ) than among the UC subjects ( 4.1 % ) ( P = .053 ) , result ing in a gross cost savings of $ 1418 US dollars per patient . With a projected program cost of $ 453 USD per patient , the return on investment is estimated at 213 % . More weight loss occurred in the SI group ( -3.68 pounds ) than in the UC group ( + .47 pounds ) ( P = .003 ) . The differences between the two groups in terms of blood pressure , lipid levels , depression scores , minutes of exercise , and dietary habits were not statistically significant . CONCLUSION An Internet-based case management system could be used as a cost-effective intervention for patients with CVD , either independently or in conjunction with traditional cardiac rehabilitation OBJECTIVES Persons with bipolar disorder experience a disproportionate burden of medical conditions , notably cardiovascular disease ( CVD ) , leading to impaired functioning and premature mortality . We hypothesized that the Life Goals Collaborative Care ( LGCC ) intervention , compared to enhanced usual care , would reduce CVD risk factors and improve physical and mental health outcomes in US Department of Veterans Affairs patients with bipolar disorder . METHOD Patients with an ICD-9 diagnosis of bipolar disorder and ≥ 1 CVD risk factor ( N = 118 ) enrolled in the Self-Management Addressing Heart Risk Trial , conducted April 2008-May 2010 , were r and omized to LGCC  ( n = 58 ) or enhanced usual care  ( n = 60 ) . Life Goals Collaborative Care included 4 weekly self-management sessions followed by tailored contacts combining health behavior change strategies , medical care management , registry tracking , and provider guideline support . Enhanced usual care included quarterly wellness newsletters sent during a 12-month period in addition to st and ard treatment . Primary outcome measures included systolic and diastolic blood pressure , nonfasting total cholesterol , and physical health-related quality of life . RESULTS Of the 180 eligible patients identified for study participation , 134 were enrolled ( 74 % ) and 118 completed outcomes assessment s ( mean age = 53 years , 17 % female , 5 % African American ) . Mixed effects analyses comparing changes in 24-month outcomes among patients in LGCC ( n = 57 ) versus enhanced usual care ( n = 59 ) groups revealed that patients receiving LGCC had reduced systolic ( β = -3.1 , P = .04 ) and diastolic blood pressure ( β = -2.1 , P = .04 ) as well as reduced manic symptoms ( β = -23.9 , P = .01 ) . Life Goals Collaborative Care had no significant impact on other primary outcomes ( total cholesterol and physical health-related quality of life ) . CONCLUSIONS Life Goals Collaborative Care , compared to enhanced usual care , may lead to reduced CVD risk factors , notably through decreased blood pressure , as well as reduced manic symptoms , in patients with bipolar disorder . TRIAL REGISTRATION Clinical Trials.gov identifier : NCT00499096 BACKGROUND Cardiovascular diseases ( CVD ) are the major cause of premature death in the world . This study was design ed to examine the physicians ' knowledge and perception of CVD risk factors and perceived implementation of CVD prevention guidelines as well as barriers to their implementation . METHODS A question naire survey by face-to-face interviews was performed among 1382 r and omly selected physicians ( general practitioners/family medicine specialists , internists and cardiologists ) from different regions of Croatia . RESULTS Most physicians believe that guidelines are useful but only 56.9 % are really using some guidelines . 40.2 % favour Joint European guidelines . More primary care physicians use their own personal experience in prevention while internists and cardiologists tend more to use the guidelines . 80.6 % believe that they treat their patients with dyslipidemia well but only 53.3 % knew the LDL-cholesterol goal value for high-risk patients and only 56.2 % knew which HDL-cholesterol level is the marker of increased risk . Hypertension was perceived as the most important risk factor , particularly by primary care physicians , while cardiologists tend to favour diabetes . Although most physicians considered the lack of financial re sources as the main barrier in CVD prevention , at the same time most of them believe that it could primarily be improved by better patient education . CONCLUSIONS Although most physicians support the guidelines use , only half of them use them and in average their knowledge of guidelines is not satisfactory . This is , together with the lack of time and finances and perceived lack of patients ' awareness , probably one of the main causes why they do not manage risk factors better Objective Community-based cardiovascular disease ( CVD ) risk factor screening programs have been used successfully in rural health improvement initiatives . However , little is known about what consumers like or dislike about them , which is a barrier to the design of future process improvements . The objective of this study was to examine the degree to which health risks and participant characteristics predicted screening satisfaction . Design This study utilized a cross-sectional survey design . Setting Data was collected as part of the broader Heart of New Ulm Project , which is a community-based CVD prevention demonstration project based in rural Minnesota . Participants There were 126 r and omly invited individuals from the CVD risk factor screenings , with 118 individuals who agreed to participate and had complete data available for analyses . Methods A multivariate logistic regression analysis was used to examine the association between demographics , lifestyle , and biometric risk factors and screening satisfaction . Results Twenty percent of respondents indicated some level of dissatisfaction with the screening process . Satisfied participants were more likely to be female ( OR=4.15 ) , not have an optimal lifestyle ( OR=3.47 ) , and have an intention to improve their lifestyle habits ( OR=3.26 ) . Age , education , and CVD risk level were not significant predictors in the final model . Conclusion Satisfaction was high in this screening program , with healthy males being least satisfied with their experience . This has implication s for the design of future intervention efforts , as they may require specific programmatic features and more specialized , targeted marketing strategies to attract a broad spectrum of participants likely to benefit Background The gap between the level of care recommended by evidence -based clinical practice guidelines and the actual care delivered to patients in practice has been well established . The Canadian Diabetes Association ( CDA ) created an implementation strategy to improve the implementation of its 2008 guidelines . This study will evaluate the impact of the strategy to improve cardiovascular disease ( CVD ) screening , prevention and treatment for people with diabetes . Design A pragmatic cluster-r and omized trial will be conducted to evaluate the CDA 's CVD Toolkit .  All family physicians in Ontario , Canada were r and omly allocated to receive the Toolkit , which includes several printed educational material s targeting CVD screening , prevention and treatment , either in spring 2009 ( intervention arm ) or in spring 2010 ( control arm ) . R and omization occurred at the level of the practice . Forty family physicians from each arm will be recruited to participate , and the medical records for 20 of their diabetic patients at high risk for CVD will be retrospectively review ed . Outcome measures will be assessed for each patient between July 2009 and March 2010 . The primary outcome will be that the patient is receiving a statin .  Secondary outcomes will include 1 ) the receipt of an angiotensin converting enzyme inhibitor or angiotensin receptor blocker , 2 ) various intermediate measures ( A1c , blood pressure , LDL-cholesterol , total-/HDL-cholesterol ratio , body mass index and waist circumference ) , and 3 ) clinical inertia ( the failure to change therapy in response to an abnormal A1c , blood pressure or cholesterol reading ) . The analysis will be carried out using multilevel hierarchical logistic regression models to account for the clustered nature of the data . The group assignment will be a physician-level variable . In addition , a process evaluation study with six focus groups of family physicians will assess the acceptability of the CDA 's Toolkit and will explore factors contributing to any change or lack of change in behaviour , from the perspectives of family physicians . Discussion Printed educational material s for physicians have been shown to exert small-to-moderate changes in patient care . The CDA 's CVD Toolkit is an example of a practice guideline implementation strategy that can be disseminated to a wide audience relatively inexpensively , and so demonstrating its effectiveness at improving diabetes care could have important consequences for guideline developers , policy makers and clinicians . Trial Registration The trial is registered with http://www . clinical trials.gov , ID # In 1998 , the American Heart Association convened Prevention Conference V to examine strategies for the identification of high-risk patients who need primary prevention . Among the strategies discussed was the measurement of markers of inflammation.1  The Conference concluded that “ many of these markers ( including inflammatory markers ) are not yet considered applicable for routine risk assessment because of : ( 1 ) lack of measurement st and ardization , ( 2 ) lack of consistency in epidemiological findings from prospect i ve studies with endpoints , and ( 3 ) lack of evidence that the novel marker adds to risk prediction over and above that already achievable through the use of established risk factors . ” The National Cholesterol Education Program Adult Treatment Panel III Guidelines identified these markers as emerging risk factors,1a which could be used as an optional risk factor measurement to adjust estimates of absolute risk obtained using st and ard risk factors . Since these publications , a large number of peer- review ed scientific reports have been published relating inflammatory markers to cardiovascular disease ( CVD ) . Several commercial assays for inflammatory markers have become available . As a consequence of the exp and ing research base and availability of assays , the number of inflammatory marker tests ordered by clinicians for CVD risk prediction has grown rapidly . Despite this , there has been no consensus from professional societies or governmental agencies as to how these assays of markers of inflammation should be used in clinical practice . On March 14 and 15 , 2002 , a workshop titled “ CDC/AHA Workshop on Inflammatory Markers and Cardiovascular Disease : Applications to Clinical and Public Health Practice ” was convened in Atlanta , Ga , to address these issues . The goals of this workshop were to determine which of the currently available tests should be used ; what results should be used to define high risk ; which patients should be tested ; and the indications for which the tests would be most useful . These 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 Background Cardiovascular diseases ( CVD ) are responsible for significant morbidity , premature mortality , and economic burden . Despite established evidence that supports the use of preventive medications among patients at high CVD risk , treatment gaps remain . Building on prior evidence and a theoretical framework , a complex intervention has been design ed to address these gaps among high-risk , under-treated patients in the Australian primary care setting . This intervention comprises a general practice quality improvement tool incorporating clinical decision support and audit/feedback capabilities ; availability of a range of CVD polypills ( fixed-dose combinations of two blood pressure lowering agents , a statin ± aspirin ) for prescription when appropriate ; and access to a pharmacy-based program to support long-term medication adherence and lifestyle modification . Methods Following a systematic development process , the intervention will be evaluated in a pragmatic cluster r and omized controlled trial including 70 general practice s for a median period of 18 months . The 35 general practice s in the intervention group  will work with a nominated partner pharmacy , whereas those in the control group will provide usual care without access to the intervention tools . The primary outcome is the proportion of patients at high CVD risk who were inadequately treated at baseline who achieve target blood pressure ( BP ) and low-density lipoprotein cholesterol ( LDL-C ) levels at the study end . The outcomes will be analyzed using data from electronic medical records , utilizing a vali date d extraction tool . Detailed process and economic evaluations will also be performed . Discussion The study intends to establish evidence about an intervention that combines technological innovation with team collaboration between patients , pharmacists , and general practitioners ( GPs ) for CVD prevention . Trial registration Australian New Zeal and Clinical Trials Registry IMPORTANCE The value of measuring levels of glycated hemoglobin ( HbA1c ) for the prediction of first cardiovascular events is uncertain . OBJECTIVE To determine whether adding information on HbA1c values to conventional cardiovascular risk factors is associated with improvement in prediction of cardiovascular disease ( CVD ) risk . DESIGN , SETTING , AND PARTICIPANTS Analysis of individual-participant data available from 73 prospect i ve studies involving 294,998 participants without a known history of diabetes mellitus or CVD at the baseline assessment . MAIN OUTCOMES AND MEASURES Measures of risk discrimination for CVD outcomes ( eg , C-index ) and reclassification ( eg , net reclassification improvement ) of participants across predicted 10-year risk categories of low ( < 5 % ) , intermediate ( 5 % to < 7.5 % ) , and high ( ≥ 7.5 % ) risk . RESULTS During a median follow-up of 9.9 ( interquartile range , 7.6 - 13.2 ) years , 20,840 incident fatal and nonfatal CVD outcomes ( 13,237 coronary heart disease and 7603 stroke outcomes ) were recorded . In analyses adjusted for several conventional cardiovascular risk factors , there was an approximately J-shaped association between HbA1c values and CVD risk . The association between HbA1c values and CVD risk changed only slightly after adjustment for total cholesterol and triglyceride concentrations or estimated glomerular filtration rate , but this association attenuated somewhat after adjustment for concentrations of high-density lipoprotein cholesterol and C-reactive protein . The C-index for a CVD risk prediction model containing conventional cardiovascular risk factors alone was 0.7434 ( 95 % CI , 0.7350 to 0.7517 ) . The addition of information on HbA1c was associated with a C-index change of 0.0018 ( 0.0003 to 0.0033 ) and a net reclassification improvement of 0.42 ( -0.63 to 1.48 ) for the categories of predicted 10-year CVD risk . The improvement provided by HbA1c assessment in prediction of CVD risk was equal to or better than estimated improvements for measurement of fasting , r and om , or postload plasma glucose levels . CONCLUSIONS AND RELEVANCE In a study of individuals without known CVD or diabetes , additional assessment of HbA1c values in the context of CVD risk assessment provided little incremental benefit for prediction of CVD risk AIMS To examine the performance of ' the Framingham 's general CVD algorithm ' in estimating 5-year risk of cardiovascular disease ( CVD ) and coronary heart disease ( CHD )  in an adult Middle Eastern community . METHODS In a population -based prospect i ve cohort , the Tehran Lipid and Glucose Study ( TLGS ) , CVD risk estimates were calculated for 3838 individuals ( 2183 women ) free of CVD at baseline . RESULTS Over 8.6 years , there were 119 CVD ( 106 CHD ) events among women , and 164 ( 137 ) among men aged ≥ 30 years . St and ard risk factors [ age , systolic blood pressure ( SBP ) , antihypertensive treatment , total and high-density lipoprotein cholesterol , smoking and diabetes mellitus ] , measured at baseline , were significantly related to the incidence of CVD . The only exception , lack of significance for coefficients of SBP among women , was attributable to collinearity between age and SBP . For most risk factors , hazard ratios ( HRs ) for CVD were similar for the TLGS and the Framingham cohorts ' participants . Few exceptions were lower HR for SBP among TLGS ' women and lower HR for age among TLGS ' men . The Framingham equations quite correctly discriminated participants [ C statistic : CVD , 0.818 ( women ) and 0.774 ( men ) ; CHD : 0.822 ( women ) and 0.751 ( men ) ] with good calibration ( all calibration χ(2 ) values < 15 , ps > 0.1 ) . DISCUSSION AND CONCLUSIONS The Framingham 's CVD algorithm was effective at ranking individuals and could be used to quantify risk and to guide preventive care in Iranian adults . For regions without established cohort , recalibration using risk factors and CVD ( CHD ) rates may be an effective method to develop CVD ( CHD ) risk prediction algorithms for local practice Although attention has recently been focused on the role of psychosocial factors in patients with cardiovascular disease ( CVD ) , the factors that have the greatest influence on prognosis have not yet been eluci date d. The aim of this study was to evaluate the effects of depression , anxiety , and anger on the prognosis of patients with CVD . Four hundred fourteen consecutive patients hospitalized with CVD were prospect ively enrolled .  Depression was evaluated using the Patient Health Question naire , anxiety using the Generalized Anxiety Disorder Question naire , and anger using the Spielberger Trait Anger Scale .  Cox proportional-hazards regression was used to examine the individual effects of depression , anxiety , and anger on a combined primary end point of cardiac death or cardiac hospitalization and on a combined secondary end point of all-cause death or hospitalization during follow-up ( median 14.2 months ) . Multivariate analysis showed that depression was a significant risk factor for cardiovascular hospitalization or death after adjusting for cardiac risk factors and other psychosocial factors ( hazard ratio 2.62 , p = 0.02 ) , whereas anxiety was not significantly associated with cardiovascular hospitalization or death after adjustment ( hazard ratio 2.35 , p = 0.10 ) . Anger was associated with a low rate of cardiovascular hospitalization or death ( hazard ratio 0.34 , p < 0.01 ) . In conclusion , depression in hospitalized patients with CVD is a stronger independent risk factor for adverse cardiac events than either anxiety or anger . Anger may help prevent adverse outcomes . Routine screening for depression should therefore be performed in patients with CVD , and the potential effects of anger in clinical practice should be reconsidered OBJECTIVE The Diabetes Prevention Program demonstrated the ability to delay or prevent type 2 diabetes in participants with impaired glucose tolerance ( IGT ) . Participants with IGT are at high risk for cardiovascular disease ( CVD ) , with a marked increase in the number and severity of CVD risk factors . We prospect ively assessed the impact of our interventions on hypertension , dyslipidemia , and CVD events . RESEARCH DESIGN AND METHODS The study group consisted of 3,234 individuals with IGT r and omly assigned to receive intensive lifestyle intervention , metformin , or placebo . Annual assessment of blood pressure , lipids , electrocardiogram , and CVD events was undertaken . RESULTS Hypertension was present in 30 % of participants at study entry and then increased in the placebo and metformin groups , although it significantly decreased with intensive lifestyle intervention . Triglyceride levels fell in all treatment groups , but fell significantly more with intensive lifestyle intervention . Total cholesterol and LDL cholesterol levels were similar among treatment groups . Intensive lifestyle intervention significantly increased the HDL cholesterol level and reduced the cumulative incidence of the proatherogenic LDL phenotype B. At 3 years of follow-up , the use for pharmacologic therapy to achieve established goals in the intensive lifestyle group was 27 - 28 % less for hypertension and 25 % less for hyperlipidemia compared with placebo and metformin groups . Over an average of 3 years , 89 CVD events from 64 participants were positively adjudicated study wide , with no differences among treatment groups . CONCLUSIONS Lifestyle intervention improves CVD risk factor status compared with placebo and metformin therapy . Although no differences in CVD events were noted after 3 years , achieved risk factor modifications suggest that longer intervention may reduce CVD event rates OBJECTIVES This study was design ed to determine whether  erectile dysfunction ( ED )  predicts cardiovascular disease ( CVD ) beyond traditional risk factors . BACKGROUND Both ED and CVD share pathophysiological mechanisms and often co-occur . It is unknown whether ED improves the prediction of CVD beyond traditional risk factors . METHODS This was a prospect i ve , population -based study of 1,709 men ( of 3,258 eligible ) age 40 to 70 years . The ED data were measured by self-report . Subjects were followed for CVD for an average follow-up of 11.7 years . The association between ED and CVD was examined using the Cox proportional hazards regression model . The discriminatory capability of ED was examined using C statistics . The reclassification of CVD risk associated with ED was assessed using a method that quantifies net reclassification improvement . RESULTS Of the prospect i ve population , 1,057 men with complete risk factor data who were free of CVD and diabetes at baseline were included . During follow-up , 261 new cases of CVD occurred . We found ED was associated with CVD incidence controlling for age ( hazard ratio [ HR ] : 1.42 , 95 % confidence interval [ CI ] : 1.05 to 1.90 ) , age and traditional CVD risk factors ( HR : 1.41 , 95 % CI : 1.05 to 1.90 ) , as well as age and Framingham risk score ( HR : 1.40 , 95 % CI : 1.04 to 1.88 ) . Despite these significant findings , ED did not significantly improve the prediction of CVD incidence beyond traditional risk factors . CONCLUSIONS Independent of established CVD risk factors , ED is significantly associated with increased CVD incidence . Nonetheless , ED does not improve the prediction of who will and will not develop CVD beyond that offered by traditional risk factors Background The increasing burden of cardiovascular diseases ( CVD ) in the ageing population of industrialized nations requires an intensive search for means of reducing this epidemic . In order to improve prevention , detection , therapy and prognosis of cardiovascular diseases on the population level in Eastern Germany , it is necessary to examine reasons for the East-West gradient of CVD morbidity and mortality , potential causal mechanisms and prognostic factors in the elderly . Psychosocial and nutritional factors have previously been discussed as possible causes for the unexplained part of the East-West gradient . A reduced heart rate variability appears to be associated with cardiovascular disease as well as with psychosocial and other cardiovascular risk factors and decreases with age . Nevertheless , there is a lack of population -based data to examine the role of heart rate variability and its interaction with psychosocial and nutritional factors regarding the effect on cardiovascular disease in the ageing population . There also is a paucity of epidemiological data describing the health situation in Eastern Germany . Therefore , we conduct a population -based study to examine the distribution of CVD , heart rate variability and CVD risk factors and their associations in an elderly East German population . This paper describes the design and objectives of the CARLA Study . Methods / design For this study , a r and om sample of 45–80 year-old inhabitants of the city of Halle ( Saale ) in Eastern Germany was drawn from the population registry . By the end of the baseline examination ( 2002–2005 ) , 1750 study participants will have been examined . A multi-step recruitment strategy aims at achieving a 70 % response rate . Detailed information is collected on own and family medical history , socioeconomic , psychosocial , behavioural and biomedical factors . Medical examinations include  anthropometric measures , blood pressure of arm and ankle , a 10-second and a 20-minute electrocardiogram , a general physical examination , an echocardiogram , and laboratory analyses of venous blood sample s.  On 200 participants , a 24-hour electrocardiogram  is recorded . A detailed system of quality control ensures high data quality . A follow-up examination is planned . Discussion This study will help to eluci date pathways to CVD involving autonomic dysfunction and lifestyle factors which might be responsible for the CVD epidemic in some population BACKGROUND AND AIM This cluster r and omized trial evaluated the efficacy of a disease and care management ( D&CM ) model in  cardiovascular ( CVD ) prevention in primary care . METHODS AND RESULTS Eligible subjects had ≥ 1 among : blood pressure ≥ 140/90 mmHg ; glycated hemoglobin ≥ 7 % ; LDL-cholesterol ≥ 160 or ≥ 100 mg/dL ( primary or secondary prevention , respectively ) ; BMI ≥ 30 ; current smoking .  The D&CM intervention included a teamwork including nurses as care managers for the implementation of tailored care plans . Control group was allocated to usual-care . The main outcome was the proportion of subjects achieving recommended clinical targets for ≥ 1 of uncontrolled CVD risk factors at 12-month . During 2008 - 2009 we enrolled 920 subjects in the Abruzzo/Marche regions , Italy . Following the exclusion of L'Aquila due to 2009 earthquake , final analyses included 762 subjects . The primary outcome was achieved by 39.1 % ( 95%CI : 34.2 - 44.2 ) and 25.2 % ( 95%CI : 20.9 - 29.9 ) of subjects in the intervention and usual-care group , respectively ( p < 0.001 ) . The D&CM intervention significantly increased the proportion of subjects who achieved clinical targets for both diabetes and hypertension , with no differences in hypercholesterolemia , smoking status and obesity . CONCLUSIONS The D&CM intervention  was effective in controlling cardiovascular risk factors , in particular hypertension and diabetes . Numbers needed to treat were small . Such intervention may deserve further consideration in clinical practice . REGISTRATION NUMBER ACTRN12611000813987 Background Although cardiorespiratory fitness ( CRF ) in childhood and adolescence may be linked to future cardiovascular health , there is currently limited evidence for a longitudinal association . Objectives To provide a systematic review on the prospect i ve association between CRF in childhood and adolescence and cardiovascular disease ( CVD ) risk factors at least 2 years later . Methods Using a systematic search of Medline , Embase , and SPORTD iscus , relevant articles were identified by the following criteria : generally healthy children and adolescents between 3 and 18 years of age with CRF assessed at baseline , and a follow-up period of ≥ 2 years . The outcome measures were CVD risk factors . We appraised quality of the included articles with STROBE and QUIPS checklists . Results After screening 7524 titles and abstract s , we included 38 articles , assessing 44,169 children and adolescents followed up for a median of 6 years . Eleven articles were of high quality . There was considerable heterogeneity in methodology , measurement of CRF , and outcomes , which hampered meta- analysis . In approximately half of the included articles higher CRF in childhood and adolescence was associated with lower body mass index ( BMI ) , waist circumference , body fatness and lower prevalence of metabolic syndrome in later life . No associations between CRF in childhood and adolescence and future waist-to-hip ratio , blood pressure , lipid profile , and glucose homeostasis were observed . Conclusion Although about half of the included articles reported inverse associations between CRF in childhood and adolescence and future BMI , body fatness , and metabolic syndrome , evidence for other CVD risk factors was unconvincing . Many articles did not account for important confounding factors such as adiposity . Recommendations for future research include st and ardizing the measurement of CRF , i.e. by reporting VO2max , using st and ardized outcome assessment s , and performing individual patient data meta-analyses INTRODUCTION This article describes the development of a community-based participatory research ( CBPR ) process conducted in the context of a r and omized community health education trial utilizing community health workers ( CHWs ) . OBJECTIVES To present lessons learned from the utilization of CBPR methodology in a cardiovascular disease ( CVD ) prevention trial among Mexican American adults in a U.S.-Mexico border community and to disseminate the baseline results associated with risk factors for CVD and their associated demographic and psychosocial characteristics . METHODS Participants were 328 Hispanic adults ages 30 - 75 with at least one risk factor for CVD ( overweight , smoking , high cholesterol , diabetic or hypertensive ) , who were recruited through approaching households in r and omly selected census tracts within a specified zip code area . RESULTS CBPR methods were applied during the different stages of the research enterprise to support the development and implementation of the intervention trial aim at reducing cardiovascular risk factors for Mexican American adults . Data from baseline were used as an important component of dialogue with the community . DISCUSSION CBPR proved to be a good learning process for all partners involved . The risk profile of the participants demonstrated the " epidemic " nature of CVD morbidity conditions associated with Mexican origin population s living in a U.S.-Mexico border community . The CBPR dialogue was instrumental as a process to help disseminate to the community the need for projects like the one described in this article CONTEXT Recent guidelines for treatment of overweight and obesity include recommendations for risk stratification by disease conditions and cardiovascular disease ( CVD ) risk factors , but the role of physical inactivity is not prominent in these recommendations . OBJECTIVE To quantify the influence of low cardiorespiratory fitness , an objective marker of physical inactivity , on CVD and all-cause mortality in normal-weight , overweight , and obese men and compare low fitness with other mortality predictors . DESIGN Prospect i ve observational data from the Aerobics Center Longitudinal Study . SETTING Preventive medicine clinic in Dallas , Tex . PARTICIPANTS A total of 25714 adult men ( average age , 43.8 years [ SD , 10.1 years ] ) who received a medical examination during 1970 to 1993 , with mortality follow-up to December 31 , 1994 . MAIN OUTCOME MEASURES Cardiovascular disease and all-cause mortality based on mortality predictors ( baseline CVD , type 2 diabetes mellitus , high serum cholesterol level , hypertension , current cigarette smoking , and low cardiorespiratory fitness ) stratified by body mass index . RESULTS During the study period , there were 1025 deaths ( 439 due to CVD ) during 258781 man-years of follow-up . Overweight and obese men with baseline CVD or CVD risk factors were at higher risk for all-cause and CVD mortality compared with normal-weight men without these predictors . Using normal-weight men without CVD as the referent , the strongest predictor of CVD death in obese men was baseline CVD ( age- and examination year-adjusted relative risk [ RR ] , 14.0 ; 95 % confidence interval [ CI ] , 9.4 - 20.8 ) ; RRs for obese men with diabetes mellitus , high cholesterol , hypertension , smoking , and low fitness were similar and ranged from 4.4 ( 95 % CI , 2.7 - 7.1 ) for smoking to 5.0 ( 95 % CI , 3.6 - 7.0 ) for low fitness . Relative risks for all-cause mortality in obese men ranged from 2.3 ( 95 % CI , 1.7 - 2.9 ) for men with hypertension to 4.7 ( 95 % CI , 3.6 - 6.1 ) for those with CVD at baseline . Relative risk for all-cause mortality in obese men with low fitness was 3.1 ( 95 % CI , 2.5 - 3.8 ) and in obese men with diabetes mellitus 3.1 ( 95 % CI , 2.3 - 4.2 ) and as slightly higher than the RRs for obese men who smoked or had high cholesterol levels . Low fitness was an independent predictor of mortality in all body mass index groups after adjustment for other mortality predictors . Approximately 50 % ( n = 1674 ) of obese men had low fitness , which led to a population -attributable risk of 39 % for CVD mortality and 44 % for all-cause mortality . Baseline CVD had population attributable risks of 51 % and 27 % for CVD and all-cause mortality , respectively . CONCLUSIONS In this analysis , low cardiorespiratory fitness was a strong and independent predictor of CVD and all-cause mortality and of comparable importance with that of diabetes mellitus and other CVD risk factors African Americans have higher rates of cardiovascular disease ( CVD ) and poorer outcomes compared to others . The American Diabetes Association and the National Diabetes Education Program have promoted use of the ABC approach ( glycated hemoglobin A1c , blood pressure , cholesterol ) for identifying and controlling the leading indicators of CVD risk . In the present study , research ers added a D factor , for depression , because this disorder is common and also predictive of CVD risk and of control of diabetes . Particularly among low-income African Americans , depression is frequently not targeted or treated . The current study tests the effectiveness of recruiting African Americans in churches and training community health workers ( CHWs ) to educate their peers about CVD and risk reduction . For the intervention group , CHWs participated in a 16-hour training session and delivered a 6-week tailored educational program with counseling sessions and demonstrations . The control group received a weekly lecture by clinical experts . The CHW active-learning intervention was more effective than lectures by clinical experts in increasing the knowledge of CVD risk . The only significant difference in clinical measures reflected a worsening of HbA1c levels in the control group ; the CHW intervention group showed a slight improvement . Participants also learned self-management skills , such as taking blood pressure , measuring glucose , and reading labels . Nevertheless , more longitudinal research and a larger sample size are needed to confirm the impact of CHWs in community setting s to change factors associated with CVD risk OBJECTIVE —Cardiovascular disease ( CVD ) mortality has decreased in men but not in women with diabetes . We investigated whether sex differences in control and treatment of CVD risk factors might underlie this disparity . RESEARCH DESIGN AND METHODS —We performed cross-sectional analyses from a cohort of patients with diabetes sample d from 10 U.S. managed care health plans . Study end points included not being in control for CVD risk factors ( ≥140 mmHg for systolic blood pressure [ SBP ] , ≥3.35 mmol/l for LDL cholesterol , and ≥8.0 % for A1C ) and the intensity of medication management ( number of medication classes ) for patients not in control . Logistic regression models with r and om intercepts were used to adjust probabilities of control and management for demographics , clinical characteristics , and clustering within health plans . RESULTS —There were 1,315 women and 1,575 men with a history of CVD and 3,415 women and 2,516 men without a history of CVD . Among patients with CVD , adjusted estimated probabilities for not being in control and risk differences varied significantly between men and women for SBP ( men 41.2 % , women 46.6 % ; risk difference −5.4 % [ 95 % CI −9.5 to −1.3 ] ) and LDL cholesterol ( men 22.4 % , women 28.3 % ; risk difference −5.9 % [ −9.9 to −1.8 ] ) . There were no significant sex differences in intensity of medication management for patients not in control . In patients without CVD there were no significant differences in control or intensity of medication management . CONCLUSIONS —In diabetic patients with CVD , poorer control of SBP and LDL cholesterol for women may contribute to the sex disparity in CVD mortality trends OBJECTIVES To examine prospect ively the association between snoring and  incidence of cardiovascular disease ( CVD ) in women . BACKGROUND Whether snoring increases risk of CVD remains unclear ; most previous studies have been small , not prospect i ve and limited to men . METHODS Seventy-one thous and seven hundred seventy-nine female nurses 40 through 65 years of age and without previously diagnosed CVD or cancer at baseline in 1986 were followed up for eight years . Frequency of snoring  was assessed using mailed question naires at baseline . RESULTS During eight years of follow-up , we documented 1,042 incident cases of major CVD events ( 644 coronary heart disease [ CHD ] and 398 stroke ) . Compared with nonsnorers , the age-adjusted relative risks ( RRs ) of CVD were 1.46 ( 95 % confidence interval 1.23 to 1.74 ) for occasional snorers and 2.02 ( 1.62 to 2.53 ) for regular snorers . The age-adjusted RRs of CHD were 1.43 ( 1.15 to 1.77 ) for occasional snorers and 2.18 ( 1.65 to 2.87 ) for regular snorers . The age-adjusted RRs of stroke were 1.60 ( 1.21 to 2.12 ) and 1.88 ( 1.29 to 2.74 ) , respectively . After further adjustment for smoking , body mass index ( BMI ) and other covariates , the positive association between snoring and CVD was attenuated but remained statistically significant ( RRs of CVD were 1.20 [ 1.01 to 1.43 ] for occasional snorers and 1.33 [ 1.06 - 1.67 ] for regular snorers . CONCLUSIONS These data suggested that snoring is associated with a modest but significantly increased risk of  CVD in women , independent of age , smoking , BMI and other cardiovascular risk factors . While further study is needed to eluci date the biological mechanism underlying this association , snoring may help clinicians identify individuals at higher risk for CVD BACKGROUND Studies suggest that moderate drinkers have lower cardiovascular disease ( CVD ) mortality than nondrinkers and heavy drinkers , but there have been no r and omized trials on this topic . Although most observational studies control for major cardiac risk factors , CVD is independently associated with other factors that could explain the CVD benefits ascribed to moderate drinking . METHODS Data from the 2003 Behavioral Risk Factor Surveillance System , a population -based telephone survey of U.S. adults , was used to assess the prevalence of CVD risk factors and potential confounders among  moderate drinkers and nondrinkers . Moderate drinkers were defined as men who drank an average of two drinks per day or fewer , or women who drank one drink or fewer per day . RESULTS After adjusting for age and gender , nondrinkers were more likely to have characteristics associated with increased CVD mortality in terms of demographic factors , social factors , behavioral factors , access to health care , and health-related conditions . Of the 30 CVD-associated factors or groups of factors that we assessed , 27 ( 90 % ) were significantly more prevalent among nondrinkers . Among factors with multiple categories ( e.g. , body weight ) , those in higher-risk groups were progressively more likely to be nondrinkers . Removing those with poor health status or a history of CVD did not affect the results . CONCLUSIONS These findings suggest that some or all of the apparent protective effect of moderate alcohol consumption on CVD may be due to residual or unmeasured confounding . Given their limitations , nonr and omized studies about the health effects of moderate drinking should be interpreted with caution , particularly since excessive alcohol consumption is a leading health hazard in the United States Background As the population ages , more people are suffering from long-term health conditions ( LTCs ) . Health services around the world are exploring new ways of supporting people with LTCs and there is great interest in the use of telehealth : technologies such as the Internet , telephone and home self-monitoring . Methods / Design This study aims to evaluate the effectiveness and cost-effectiveness of a telehealth intervention delivered by NHS Direct to support patients with LTCs . Two r and omized controlled trials will be conducted in parallel , recruiting patients with two exemplar LTCs : depression or raised cardiovascular disease ( CVD ) risk . A total of 1,200 patients will be recruited from approximately 42 general practice s near Bristol , Sheffield and Southampton , UK . Participants will be r and omly allocated to either usual care ( control group ) or usual care plus the NHS Direct Healthlines Service ( intervention group ) . The intervention is based on a conceptual model incorporating promotion of self-management , optimisation of treatment , coordination of care and engagement of patients and general practitioners . Participants will be provided with tailored help , combining telephone advice from health information advisors with support to use a range of online re sources . Participants will access the service for 12 months . Outcomes will be collected at baseline , four , eight and 12 months for the depression trial and baseline , six and 12 months for the CVD risk trial . The primary outcome will be the proportion of patients responding to treatment , defined in the depression trial as a PHQ-9 score < 10 and an absolute reduction in PHQ-9 ≥5 after 4 months , and in the CVD risk trial as maintenance or reduction of 10-year CVD risk after 12 months . The study will also assess whether the intervention is cost-effective from the perspective of the NHS and personal social services . An embedded qualitative interview study will explore healthcare professionals ’ and patients ’ views of the intervention . Discussion This study evaluates a complex telehealth intervention which combines evidence -based components and is delivered by an established healthcare organisation . The study will also analyse health economic information . In doing so , the study hopes to address some of the limitations of previous research by demonstrating the effectiveness and cost-effectiveness of a real world telehealth intervention . Trial registration Current Controlled Trials : Depression trial IS RCT N14172341 and cardiovascular disease risk trial IS RCT N27508731 Background People with severe mental illnesses ( SMI ) are at increased risk of cardiovascular disease ( CVD ) . Clinical guidelines recommend regular screening for CVD risk factors . We evaluated a nurse led intervention to improve screening rates across the primary - secondary care interface . Methods Six community mental health teams ( CMHTs ) were r and omised to receive either the nurse led intervention plus education pack ( n = 3 ) or education pack only ( n = 3 ) . Intervention ( 6 months ) : The nurse promoted CVD screening in primary care and then in CMHTs . Patients who remained unscreened were offered screening by the nurse . After the intervention participants with SMI were recruited from each CMHT to collect outcome data . Main outcome : Numbers screened during the six months , confirmed in General Practice notes . Results All six CMHTs approached agreed to r and omisation . 121 people with SMI participated in outcome interviews during two waves of recruitment ( intervention arm n = 59 , control arm n = 62 ) . Participants from both arms of the trial had similar demographic profiles and rates of previous CVD screening in the previous year , with less than 20 % having been screened for each risk factor . After the trial , CVD screening had increased in both arms but participants from the intervention arm were significantly more likely to have received screening for blood pressure ( 96 % vs 68 % ; adjusted Odds Ratio ( OR ) 13.6 ; 95 % CI : 3.5 - 38.4 ) , cholesterol ( 66.7 % vs 26.9 % , OR 6.1 ; 3.2 - 11.5 ) , glucose ( 66.7 % vs 36.5 % OR 4.4 ; 2.7 - 7.1 ) , BMI ( 92.5 % vs 65.2 % OR 6.5 ; 2.1 - 19.6 ) , and smoking status ( 88.2 % vs 57.8 % OR 5.5 ; 3.2 - 9.5 ) and have a 10 year CVD risk score calculated ( 38.2 % vs 10.9 % ) OR 5.2 1.8 - 15.3 ) . Within the intervention arm approximately half the screening was performed in general practice and half by the trial nurse . Conclusions The nurse-led intervention was superior , result ing in an absolute increase of approximately 30 % more people with SMI receiving screening for each CVD risk factor . The feasibility of the trial was confirmed in terms of CMHT recruitment and the intervention , but the response rate for outcome collection was disappointing ; possibly a result of the cluster design . The trial was not large or long enough to detect changes in risk factors . Trial Registration International St and ard R and omised Controlled Trial Registration Number ( IS RCT RN ) 58625025 Few data exist on the effectiveness of cardiovascular disease ( CVD ) risk-reduction programs in patients with limited access to health care . The objective of this project was to evaluate a disease management approach to multifactor CVD risk reduction in patients with limited or no health insurance and low family income . Patients ( n = 148 ) were recruited from not-for-profit or free clinics and hospitals and r and omized to usual care or usual care plus team case management . Mean age was 59.3 years , 57 % were women , 50 % had less than a high school education , 57 % were Hispanic , and 64 % had no health insurance . All had > or = 1 increased risk factor for CVD , and 24.5 % had documented coronary artery disease . Follow-up measurements were obtained at 6 and 12 months . Primary outcomes were low-density lipoprotein cholesterol and systolic blood pressure . The disease management program was supervised by a physician , delivered by nurses and dietitians , and included comprehensive lifestyle changes and medications . Data were collected on 91 % of patients at 12 months . Disease management produced clinical ly important decreases in selected risk factors compared with usual care , including systolic blood pressure ( p < 0.01 ) and low-density lipoprotein cholesterol ( p < 0.03 ) . More patients with disease management than those with usual care moved from " high " and " very-high " risk to lower risk categories for selected risk factors . In conclusion , the disease management program had excellent retention and lower CVD risk factors and demonstrated the potential of such approaches for decreasing long-term disease burden in selected medically underserved population Globally , cardiovascular disease ( CVD ) is the number one cause of death , being responsible for approximately 30 % of deaths worldwide . Urbanization and a westernized lifestyle are thought to play a major role in the development of CVD . There is accumulating evidence that vitamin D is a nonclassical risk factor for CVD . The active vitamin D metabolite , 1,25-dihydroxyvitamin D , which is synthesized from its precursor 25-hydroxyvitamin D ( 25[OH]D ) , down-regulates several negative and up-regulates various protective pathways in the heart and vasculature . First r and omized trials demonstrate that vitamin D supplementation leads to vasodilatation and suppresses cardiovascular risk markers such as triglycerides and the inflammation marker tumor necrosis factor-α . Solar UV-B radiation is the major source of vitamin D for humans . Consequently , the vitamin D status is largely influenced by season , geographic latitude , daily outdoor activities , and the percentage of body surface exposed to solar UV-B. A significant proportion of individuals in Europe and North America have  vitamin D concentrations in the deficiency range ( 25[OH]D<25 nmol/l ) . Available data indicate that low solar UV-B exposure and /or low 25(OH)D concentrations are associated with an increased risk of CVD . Large nonr and omized studies indicate that CVD mortality is more than twice as high in older individuals with deficient 25(OH)D concentrations compared with those individuals who have adequate 25(OH)D concentrations ( > 75 nmol/l ) . Together , experimental and epidemiological evidence does support a plausible role for improving vitamin D status in CVD prevention in the population at large . Nevertheless , future r and omised clinical trials are needed to evaluate whether vitamin D is effective with respect to primary , secondary , and /or tertiary prevention of CVD Background Although disease-specific exercise guidelines for cardiovascular disease ( CVD ) are widely available , it remains uncertain whether these different exercise guidelines are integrated properly for patients with different CVDs . The aim of this study was to assess the inter-clinician variance in exercise prescription for patients with various CVDs and to compare these prescriptions with recommendations from the EXercise Prescription in Everyday practice and Rehabilitative Training ( EXPERT ) tool , a digital decision support system for integrated state-of-the-art exercise prescription in CVD . Design The study was a prospect i ve observational survey . Methods Fifty-three CV rehabilitation clinicians from nine European countries were asked to prescribe exercise intensity ( based on percentage of peak heart rate ( HRpeak ) ) , frequency , session duration , programme duration and exercise type ( endurance or strength training ) for the same five patients . Exercise prescriptions were compared between clinicians , and relationships with clinician characteristics were studied . In addition , these exercise prescriptions were compared with recommendations from the EXPERT tool . Results A large inter-clinician variance was found for prescribed exercise intensity ( median ( interquartile range ( IQR ) ) : 83 ( 13 ) % of HRpeak ) , frequency ( median ( IQR ) : 4 ( 2 ) days/week ) , session duration ( median ( IQR ) : 45 ( 18 ) min/session ) , programme duration ( median ( IQR ) : 12 ( 18 ) weeks ) , total exercise volume ( median ( IQR ) : 1215 ( 1961 ) peak-effort training hours ) and prescription of strength training exercises  ( prescribed in 78 % of all cases ) . Moreover , clinicians ’ exercise prescriptions were significantly different from those of the EXPERT tool ( p < 0.001 ) . Conclusions This study reveals significant inter-clinician variance in exercise prescription for patients with different CVDs and disagreement with an integrated state-of-the-art system for exercise prescription , justifying the need for st and ardization efforts regarding integrated exercise prescription in CV rehabilitation OBJECTIVES This study was design ed to examine the hypothesis that higher intake of dietary fiber is inversely related to the  risk of cardiovascular disease ( CVD ) and myocardial infa rct ion ( MI ) in a large prospect i ve cohort of women . BACKGROUND Although dietary fiber has been suggested to reduce the risk of coronary disease , few prospect i ve studies have examined the association between the types and amounts of dietary fiber and CVD risk , particularly among women . METHODS In 1993 , we used a semi-quantitative food frequency question naire to assess dietary fiber intake among 39,876 female health professionals with no previous history of CVD or cancer . Women were subsequently followed for an average of six years for incidence of nonfatal MI , stroke , percutaneous transluminal coronary angioplasty , coronary artery bypass graft or death due to CVD confirmed by medical records or death certificates . RESULTS During 230,006 person-years of follow-up , 570 incident cases of CVD were documented , including 177 MIs . After adjustment for age and r and omized treatment status , a significant inverse association was observed between dietary fiber intake and CVD risk . Comparing the highest quintile of fiber intake ( median : 26.3 g/day ) with the lowest quintile ( median : 12.5 g/day ) , the relative risks ( RR ) were 0.65 ( 95 % confidence interval [ CI ] : 0.51 , 0.84 ) for total CVD and 0.46 ( 95 % CI : 0.30 , 0.72 ) for MI . Additional adjustment for CVD risk factors reduced the RRs to 0.79 ( 95 % CI : 0.58 , 1.09 ) for total CVD and 0.68 ( 95 % CI : 0.36 , 1.22 ) for MI . The inverse trends across categories generally remained , although they were no longer statistically significant . Inverse relations were observed between both soluble and insoluble fiber and risk of CVD and MI , and among those who had never smoked and those with body mass index < 25 . CONCLUSIONS A higher intake of  dietary fiber was associated with a lower risk of CVD and MI , although the association was not statistically significant after further adjusting for multiple confounding factors . Nevertheless , these prospect i ve data generally support current dietary recommendations to increase the consumption of fiber-rich whole grains and fruits and vegetables as a primary preventive measure against CVD
Results were inconsistent for changes in CVD risk factors such as systolic and diastolic blood pressure , total and low-density lipoprotein cholesterol , and hemoglobin A1C levels .
CONCLUSIONS CDSSs are effective in improving clinician practice s related to screening and other preventive care services , clinical tests , and treatments .
CONTEXT Clinical decision support systems ( CDSSs ) can help clinicians assess cardiovascular disease ( CVD ) risk and manage CVD risk factors by providing tailored assessment s and treatment recommendations based on individual patient data .
The goal of this systematic review was to examine the effectiveness of CDSSs in improving screening for CVD risk factors , practice s for CVD-related preventive care services such as clinical tests and prescribed treatments , and management of CVD risk factors .