Global Risk Assessment to Guide Blood Pressure Management in Cardiovascular Disease Prevention Lifestyle‐Based Prediction Model for the Prevention of CVD: The Healthy Heart Score Information and Risk Modification Trial (INFORM): design of a randomised controlled trial of communicating different types of information about coronary heart disease risk, alongside lifestyle advice, to achieve change in health-related behaviour Knowledge, Attitudes and Cardiovascular Risk Factors in Danish Adults A multifaceted quality improvement intervention for CVD risk management in Australian primary healthcare: a protocol for a process evaluation Evaluating the use of mobile phone technology to enhance cardiovascular disease screening by community health workers A randomised controlled trial of providing personalised cardiovascular risk information to modify health behaviour Laboratory-based and office-based risk scores and charts to predict 10-year risk of cardiovascular disease in 182 countries: a pooled analysis of prospective cohorts and health surveys. Rationale and design of the Rural Andhra Pradesh Cardiovascular Prevention Study (RAPCAPS): a factorial, cluster-randomized trial of 2 practical cardiovascular disease prevention strategies developed for rural Andhra Pradesh, India. Blood Pressure and Risk of Secondary Cardiovascular Events in Women: The Women’s Antioxidant Cardiovascular Study (WACS) 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 Risk functions for prediction of cardiovascular disease in elderly Australians: the Dubbo Study. Cardiovascular disease risk factors, depression symptoms and antidepressant medicine use in the Look AHEAD (Action for Health in Diabetes) clinical trial of weight loss in diabetes National Study of Physician Awareness and Adherence to Cardiovascular Disease Prevention Guidelines Results of a five-year community-based programme for cardiovascular disease prevention: The ATS-Sardegna Campaign Absolute Cardiovascular Disease Risk and Shared Decision Making in Primary Care: A Randomized Controlled Trial The systematic coronary risk evaluation (SCORE) for the prevention of cardiovascular diseases. Does evidence exist for its effectiveness? A systematic review EDUCORE project: a clinical trial, randomised by clusters, to assess the effect of a visual learning method on blood pressure control in the primary healthcare setting IMProving Adherence using Combination Therapy (IMPACT): design and protocol of a randomised controlled trial in primary care. Pneumococcal infection and immunologic response to pneumococcal vaccine in chronic obstructive pulmonary disease. A pilot study. Predictive ability of the SCORE Belgium risk chart for cardiovascular mortality. The Effectiveness of Pharmacist Interventions on Cardiovascular Risk: The Multicenter Randomized Controlled RxEACH Trial. Glycated hemoglobin measurement and prediction of cardiovascular disease.
Elevated blood pressure ( BP ) is a causal risk factor for cardiovascular disease ( CVD ) . Epidemiological analyses have established the grade d and continuous association between higher BP and CVD . Moreover , r and omized clinical trials among individuals with hypertension have demonstrated , in aggregate , a reduction in CVD events by 20 % , coronary heart disease ( CHD ) by 17 % , stroke by 27 % , and heart failure by 28 % for every 10 mm Hg systolic BP ( SBP ) lowering with medical therapy.1 Therefore , prevention , detection , treatment , and control of elevated BP , and its clinical correlate hypertension , is an important public health priority and a primary target for CVD prevention . Although national health surveys have demonstrated improvements in hypertension awareness and treatment , strategic opportunities to improve the efficiency and efficacy of applying BP-lowering therapy in patients most likely to benefit remain.2 Global CVD risk assessment , using multivariable prediction models that estimate absolute CVD risk from routinely measured clinical variables , has been promulgated in several CVD prevention guidelines for cholesterol management to target the most intensive preventive therapies to those at highest absolute CVD risk.3–5 Hypertension guidelines , however , have instead relied solely on isolated BP thresholds and BP goals to guide treatment initiation and intensity . In this review , we provide a rationale for incorporating global CVD risk assessment in BP treatment decision-making and propose a framework to guide its implementation in future CVD prevention guidelines . Epidemiological analyses have firmly established that CVD is a multifactorial condition and that modest increases of several CVD risk factors can often lead to greater overall risk than a severe elevation of a Background Clinical practice focuses on the primary prevention of  cardiovascular ( CV ) disease ( CVD ) through the modification and pharmacological treatment of elevated risk factors . Prediction models based on established risk factors are available for use in the primary prevention setting . However , the prevention of risk factor development through healthy lifestyle behaviors , or primordial prevention , is of paramount importance to achieve optimal population ‐wide CV health and minimize long‐term CVD risk . Methods and Results We developed a  lifestyle‐based CVD prediction model among 61 025 women in the Nurses ’ Health Study and 34 478 men in the Health Professionals Follow‐up Study , who were free of chronic disease in 1986 and followed for ≤24 years .  Lifestyle factors  were assessed by question naires in 1986 . In the derivation step , we used the Bayes Information Criterion to create parsimonious 20‐year risk prediction models among a r and om two thirds of participants in each cohort separately . The scores were vali date d in the remaining one third of participants in each cohort . Over 24 years , there were 3775 cases of CVD in women and 3506 cases in men . The Healthy Heart Score included age , smoking , body mass index , exercise , alcohol , and a composite diet score . In the validation cohort , the risk score demonstrated good discrimination ( Harrell 's C‐index , 0.72 ; 95 % confidence interval [ CI ] , 0.71 , 0.74 [ women ] ; 0.77 ; 95 % CI , 0.76 , 0.79 [ men ] ) , fit , and calibration , particularly among individuals without baseline hypertension or hypercholesterolemia . Conclusions The Healthy Heart Score accurately identifies individuals at elevated risk for CVD and may serve as an important clinical and public health screening tool for the primordial prevention of CVD Background Cardiovascular disease ( CVD ) remains the leading cause of death globally . Primary prevention of CVD requires cost-effective strategies to identify individuals at high risk in order to help target preventive interventions . An integral part of this approach is the use of CVD risk scores . Limitations in previous studies have prevented reliable inference about the potential advantages and the potential harms of using CVD risk scores as part of preventive strategies . We aim to evaluate short-term effects of providing different types of information about coronary heart disease ( CHD ) risk , alongside lifestyle advice , on health-related behaviours . Methods / Design In a parallel-group , open r and omised trial , we are allocating 932 male and female blood donors with no previous history of CVD aged 40–84 years in Engl and to either no intervention ( control group ) or to one of three active intervention groups : i ) lifestyle advice only ; ii ) lifestyle advice plus information on estimated 10-year CHD risk based on phenotypic characteristics ; and iii ) lifestyle advice plus information on estimated 10-year CHD risk based on phenotypic and genetic characteristics . The primary outcome is change in objective ly measured physical activity . Secondary outcomes include : objective ly measured dietary behaviours ; cardiovascular risk factors ; current medication and healthcare usage ; perceived risk ; cognitive evaluation of provision of CHD risk scores ; and psychological outcomes . The follow-up assessment takes place 12 weeks after r and omisation . The experiences , attitudes and concerns of a subset of participants will be also studied using individual interviews and focus groups . Discussion The INFORM study has been design ed to provide robust findings about the short-term effects of providing different types of information on estimated 10-year CHD risk and lifestyle advice on health-related behaviours . Trial registration Current Controlled Trials IS RCT N17721237 . Registered 12 January 2015 A community cardiovascular disease ( CVD ) prevention programme was undertaken in 1989 in a Danish County ( Vejle ) . A r and om sample of 5192 adults were asked to complete a mailed question naire on  knowledge , attitudes , and behaviour  in relation to CVD risk factors . The response rate was 56 % . The question naire produced baseline data for programme planning and measuring the success of on-going interventions . Smoking , overweight , and unhealthy food habits were the most prevalent CVD risk factors . A CVD risk score was calculated from the data on smoking , food habits , exercise , stress , overweight , self-reported presence of hypertension , diabetes , and gender . A high score was commoner in men , in the least educated , in groups who judged their own risk as high , and in groups with negative health beliefs . The level of knowledge about CVD risk factors was high in general . Low knowledge was commonest in the youngest age group , in the least educated , in unskilled workers , and in groups with negative health beliefs . As social position and personality factors seem to play an important role in actions people may take in prevention of CVD , they should be considered in the planning of the health promotion activities in Vejle Background Cardiovascular disease ( CVD ) is the leading cause of death and disability worldwide . Despite the widespread availability of evidence -based clinical guidelines and vali date d risk predication equations for prevention and management of CVD , their translation into routine practice is limited . We developed a multifaceted quality improvement intervention for CVD risk management which incorporates electronic decision support , patient risk communication tools , computerised audit and feedback tools , and monthly , peer-ranked performance feedback via a web portal . The intervention was implemented in a cluster r and omised controlled trial in 60 primary healthcare services in Australia . Overall , there were improvements in risk factor recording and in prescribing of recommended treatments among under-treated individuals , but it is unclear how this intervention was used in practice and what factors promoted or hindered its use . This information is necessary to optimise intervention impact and maximally implement it in a post-trial context . In this study protocol , we outline our methods to conduct a theory-based , process evaluation of the intervention . Our aims are to underst and how , why , and for whom the intervention produced the observed outcomes and to develop effective strategies for translation and dissemination . Methods / Design We will conduct four discrete but inter-related studies taking a mixed methods approach . Our quantitative studies will examine ( 1 ) the longer term effectiveness of the intervention post-trial , ( 2 ) patient and health service level correlates with trial outcomes , and ( 3 ) the health economic impact of implementing the intervention at scale . The qualitative studies will ( 1 ) identify healthcare provider perspectives on implementation barriers and enablers and ( 2 ) use video ethnography and patient semi-structured interviews to underst and how cardiovascular risk is communicated in the doctor/patient interaction both with and without the use of intervention . We will also assess the costs of implementing the intervention in Australian primary healthcare setting s which will inform scale-up considerations . Discussion This mixed methods evaluation will provide a detailed underst and ing of the process of implementing a  quality improvement intervention and identify the factors that might influence scalability and sustainability . Trials registration 12611000478910 BACKGROUND Primary prevention of cardiovascular disease (CVD),by identifying individuals at risk is a well-established , but costly strategy when based on measurements that depend on laboratory analyses . A non-laboratory , paper-based CVD risk assessment chart tool has previously been developed to make screening more affordable in developing countries . Task shifting to community health workers ( CHWs ) is being investigated to further scale CVD risk screening . This study aim ed to develop a mobile phone CVD risk assessment application and to evaluate its impact on CHW training and the duration of screening for CVD in the community by CHWs . METHODS A feature phone application was developed using the open source online platform , CommCare ( © ) . CHWs ( n=24 ) were trained to use both paper-based and mobile phone CVD risk assessment tools . They were r and omly allocated to using one of the risk tools to screen 10 - 20 community members and then crossed over to screen the same number , using the alternate risk tool . The impact on CHW training time , screening time and margin of error in calculating risk scores was recorded . A focus group discussion evaluated experiences of CHWs using the two tools . RESULTS The training time was 12.3h for the paper-based chart tool and 3h for the mobile phone application . 537 people were screened . The mean screening time was 36 min ( SD=12.6 ) using the paper-base chart tool and 21 min ( SD=8.71 ) using the mobile phone application , p=<0.0001 . Incorrect calculations ( 4.3 % of average systolic BP measurements , 10.4 % of BMI and 3.8 % of CVD risk score ) were found when using the paper-based chart tool while all the mobile phone calculations were correct . Qualitative findings from the focus group discussion corresponded with the findings of the pilot study . CONCLUSION The reduction in CHW training time , CVD risk screening time , lack of errors in calculation of a CVD risk score and end user satisfaction when using a mobile phone application , has implication s in terms of adoption and sustainability of this primary prevention strategy to identify people with high CVD risk who can be referred for appropriate diagnoses and treatment We conducted a feasibility study of a web-based intervention , which provided personalized cardiovascular disease ( CVD ) risk information , behavioural risk reduction strategies and educational re sources . Participants were block-r and omized to the 3-month intervention ( n = 47 ) or to usual care ( n = 49 ) . Participants in the intervention group were presented with their CVD risk based on the Framingham risk score , and in three subsequent online encounters could select two behavioural/lifestyle modules , giving them an opportunity to complete six modules over the course of the study . Because it was self-guided , participants had differing levels of engagement with intervention material s. Most intervention group participants ( 77 % , n = 36 ) completed all modules . After 3 months there were no significant differences between the intervention and usual care groups for systolic blood pressure , body-mass index , CVD risk , smoking cessation or medication non-adherence . The study suggests that modest clinical improvements can be achieved by interventions that are entirely web-administered . However , web-based interventions do not replace the need for human interaction to communicate CVD risk and assist with decision-making BACKGROUND Worldwide implementation of risk-based cardiovascular disease ( CVD ) prevention requires risk prediction tools that are contemporarily recalibrated for the target country and can be used where laboratory measurements are unavailable . We present two cardiovascular risk scores , with and without laboratory-based measurements , and the corresponding risk charts for 182 countries to predict 10-year risk of fatal and non-fatal CVD in adults aged 40 - 74 years . METHODS Based on our previous laboratory-based prediction model ( Globorisk ) , we used data from eight prospect i ve studies to estimate coefficients of the risk equations using proportional hazard regressions . The laboratory-based risk score included age , sex , smoking , blood pressure , diabetes , and total cholesterol ; in the non-laboratory ( office-based ) risk score , we replaced diabetes and total cholesterol with BMI . We recalibrated risk scores for each sex and age group in each country using country-specific mean risk factor levels and CVD rates . We used recalibrated risk scores and data from national surveys ( using data from adults aged 40 - 64 years ) to estimate the proportion of the population at different levels of CVD risk  for ten countries from different world regions as examples of the information the risk scores provide ; we applied a risk threshold for high risk of at least 10 % for high-income countries ( HICs ) and at least 20 % for low-income and middle-income countries ( LMICs ) on the basis of national and international guidelines for CVD prevention . We estimated the proportion of men and women who were similarly categorised as high risk or low risk by the two risk scores . FINDINGS Predicted risks for the same risk factor profile were generally lower in HICs than in LMICs , with the highest risks in countries in central and southeast Asia and eastern Europe , including China and Russia . In HICs , the proportion of people aged 40 - 64 years at high risk of CVD ranged from 1 % for South Korean women to 42 % for Czech men ( using a ≥10 % risk threshold ) , and in low-income countries ranged from 2 % in Ug and a ( men and women ) to 13 % in Iranian men ( using a ≥20 % risk threshold ) . More than 80 % of adults were similarly classified as low or high risk by the laboratory-based and office-based risk scores . However , the office-based model substantially underestimated the risk among patients with diabetes . INTERPRETATION Our risk charts provide risk assessment tools that are recalibrated for each country and make the estimation of CVD risk possible without using laboratory-based measurements . FUNDING National Institutes of Health BACKGROUND Developing countries are experiencing increasing levels of cardiovascular disease ( CVD ) . Although there is a good underst and ing of how to deliver CVD prevention programs in developed countries , there are few data regarding strategies for CVD prevention in re source -poor setting s. This study aim ed to implement and evaluate a CVD prevention program in a rural area of India . METHODS The 2 strategies of CVD prevention to be investigated are an algorithm-based care approach and a health-promotion campaign . A factorial , cluster-r and omized trial design will be used to evaluate these , in which villages will be exposed to one , both , or neither of the interventions for a period of about 12 months . Surveys of households in every village will be used to assess outcomes in all high-risk individuals and a sample of the general adult population . RESULTS The primary outcome of the algorithm-based component of this study will be the percentage of high-risk individuals that have been " identified"-defined as having received a cardiovascular-risk assessment in the last 12 months . The primary outcome for the health-promotion component will be the percentage of the adult population with correct knowledge about the effects of 6 behavioral determinants of cardiovascular risk ( green-leafy vegetables , fruits , oily foods , salt , smoking , physical activity ) . Secondary outcomes include a range of measures defining uptake of different preventive strategies . CONCLUSIONS This study will provide evidence about the effectiveness of a simple practical mechanism of CVD preventive care specifically design ed for delivery in a re source -poor area in India Background —In apparently healthy people , the relation between blood pressure and risk of subsequent cardiovascular disease ( CVD ) is linear . In persons with CVD , the relation is uncertain . Methods and Results —We conducted a prospect i ve study of 5218 older women with CVD who reported their blood pressure at baseline in the Women ’s Antioxidant Cardiovascular Study ( WACS ) , an ongoing double-blind , placebo-controlled secondary prevention trial of the benefits and risks of antioxidant vitamins , folic acid , vitamin B6 , and vitamin B12 among women with CVD or ≥3 coronary risk factors . A total of 661 confirmed CVD events ( nonfatal myocardial infa rct ion , nonfatal stroke , coronary artery bypass graft procedure , percutaneous coronary angioplasty , or CVD death ) occurred during a median follow-up of 6.5 years . After controlling for age , r and omized treatment assignment , antihypertensive medication use , and coronary risk factors , we found that systolic blood pressure ( SBP ) was a strong predictor of CVD events and that the relation between SBP and CVD risk was positive , continuous , and linear ( P for linear trend=0.001 ) . For each 10-mm Hg increment in SBP , there was a 9 % ( 95 % CI 4 % to 15 % ) increase in risk of secondary CVD events . Diastolic blood pressure , mean arterial pressure , and pulse pressure were weaker predictors of CVD risk in this cohort , and joint consideration of SBP and diastolic blood pressure found that only SBP significantly predicted risk . Use of antihypertensive medication did not modify the relationship of SBP with CVD events . Conclusions —In this population of women with CVD , we observed a strong , continuous , and linear association between SBP and risk of secondary CVD events . SBP was the blood pressure measure most strongly related to CVD risk Background Cardiovascular diseases ( CVD ) are responsible for significant morbidity , premature mortality , and economic burden . Despite established evidence that supports the use of preventive medications among patients at high CVD risk , treatment gaps remain . Building on prior evidence and a theoretical framework , a complex intervention has been design ed to address these gaps among high-risk , under-treated patients in the Australian primary care setting . This intervention comprises a general practice quality improvement tool incorporating clinical decision support and audit/feedback capabilities ; availability of a range of CVD polypills ( fixed-dose combinations of two blood pressure lowering agents , a statin ± aspirin ) for prescription when appropriate ; and access to a pharmacy-based program to support long-term medication adherence and lifestyle modification . Methods Following a systematic development process , the intervention will be evaluated in a pragmatic cluster r and omized controlled trial including 70 general practice s for a median period of 18 months . The 35 general practice s in the intervention group  will work with a nominated partner pharmacy , whereas those in the control group will provide usual care without access to the intervention tools . The primary outcome is the proportion of patients at high CVD risk who were inadequately treated at baseline who achieve target blood pressure ( BP ) and low-density lipoprotein cholesterol ( LDL-C ) levels at the study end . The outcomes will be analyzed using data from electronic medical records , utilizing a vali date d extraction tool . Detailed process and economic evaluations will also be performed . Discussion The study intends to establish evidence about an intervention that combines technological innovation with team collaboration between patients , pharmacists , and general practitioners ( GPs ) for CVD prevention . Trial registration Australian New Zeal and Clinical Trials Registry OBJECTIVES To evaluate a Framingham risk function for coronary heart disease in an elderly Australian cohort and to derive a risk function for cardiovascular disease ( CVD ) in elderly Australians . DESIGN AND SETTING Analysis of data from a prospect i ve cohort study ( the Dubbo Study ) in a semi-urban town ( population , 34 000 ) . PARTICIPANTS 2805 men and women 60 years and older living in the community , first assessed in 1988 , and a subcohort of 2102 free of CVD at study entry . MAIN OUTCOME MEASURES Incidence of CVD ( myocardial infa rct ion , coronary death or stroke ) over 5 and 10 years . RESULTS A Framingham risk function assessing " hard " coronary heart disease ( ie , myocardial infa rct ion or coronary death ) accurately predicted 10-year incidence in men and women aged 60 - 79 years who were free of prevalent CVD or diabetes at study entry . In a multiple logistic model , CVD incidence was significantly predicted by age , sex , taking antihypertensive medication , blood pressure , smoking , total cholesterol level and diabetes . For a given age and cholesterol level , CVD risk over 5 years was doubled in the presence of antihypertensive medication or diabetes , increased by 50 % with cigarette smoking , and halved in women compared with men . CONCLUSIONS We have derived a simple CVD risk function specifically for elderly Australians that employs risk factors readily accessible to all medical practitioners Aims /hypothesisTo determine the associations of baseline depression symptoms and use of antidepressant medicines ( ADMs ) with baseline cardiovascular disease ( CVD ) risk factors in Look AHEAD ( Action for Health in Diabetes ) trial participants . Methods Look AHEAD participants ( n = 5,145 ; age 58.7 ± 6.8 years ; BMI 35.8 ± 5.8 kg/m2 ) were assessed for CVD risk factors ( elevated HbA1c or insulin use , elevated BP or antihypertensive use , elevated lipid levels or lipid-lowering medication , current smoking , BMI ≥30 kg/m2 , lower peak exercise capacity assessed as metabolic equivalents [ METs ] , and ankle – brachial index < 0.9 or > 1.3 ) . Participants also completed the Beck Depression Inventory ( BDI ) and reported their use of ADMs . Results Of the participants , 14.7 % had BDI scores ≥11 , consistent with mild-moderate depression , and 16.5 % took ADMs ; 4.4 % had both depression markers ( i.e. elevated symptom scores and took ADMs ) . In logistic regression analyses of CVD risk ( elevated risk factor or use of medication to control the risk factor ) , controlled for demographic factors , continuous BDI  scores and ADM use were each independently associated with elevated BP ( or medication ) , current smoking , BMI ≥30 kg/m2 and lower MET values . ADM use was also associated with elevated serum lipids or use of lipid-lowering medication . Conclusions /interpretationAmong Look AHEAD participants , depression symptoms or ADM use on entry to the study were each independently associated with a wide range of CVD risk factors . Future research should assess the temporal dynamics of the relationships  of depression symptoms and ADM use with CVD risk factors . Trial registration Clinical trials.gov NCT00017953 Funding This study is funded by the National Institutes of Health with additional support from the Centers for Disease Control and Prevention Background —Few data have evaluated physician adherence to cardiovascular disease ( CVD ) prevention guidelines according to physician specialty or patient characteristics , particularly gender . Methods and Results —An online study of 500 r and omly selected physicians ( 300 primary care physicians , 100 obstetricians/gynecologists , and 100 cardiologists ) used a st and ardized question naire to assess awareness of , adoption of , and barriers to national CVD prevention guidelines by specialty . An experimental case study design tested physician accuracy and determinants of CVD risk level assignment and application of guidelines among high- , intermediate- , or low-risk patients . Intermediate-risk women , as assessed by the Framingham risk score , were significantly more likely to be assigned to a lower-risk category by primary care physicians than men with identical risk profiles ( P<0.0001 ) , and trends were similar for obstetricians/gynecologists and cardiologists . Assignment of risk level significantly predicted recommendations for lifestyle  and preventive pharmacotherapy . After adjustment for risk assignment , the impact of patient gender on preventive care was not significant except for less aspirin ( P<0.01 ) and more weight management recommended ( P<0.04 ) for intermediate-risk women . Physicians did not rate themselves as very effective in their ability to help patients prevent CVD . Fewer than 1 in 5 physicians knew that more women than men die each year from CVD . Conclusions —Perception of risk was the primary factor associated with CVD preventive recommendations . Gender disparities in recommendations for preventive therapy were explained largely by the lower perceived risk despite similar calculated risk for women versus men . Educational interventions for physicians are needed to improve the quality of CVD preventive care and lower morbidity and mortality from CVD for men and women The objective of this study was to evaluate the effects of the ATS-Sardegna Campaign on lifestyle and cardiovascular disease ( CVD ) risk factors in the Sardinian population . The Campaign was a community-based public health action programme funded by the Sardinian Government with a view to prevent CVD and promote healthy behaviour . It was also part of the Targeted Project FAT.MA . of the Italian National Research Council ( CNR ) , with the main purpose of evaluating the effects of this public health initiative after a five- year intervention . The evaluation was effected with three parallel procedures : individual interviews with 1486 r and omly chosen people ; assessment of eating patterns through a food-frequency question  naire ; measurement of the mean levels of the major CVD risk factors in 1729 r and omly chosen subjects ( 1044 in the calendar year 1992 , and 685 in 1995 , two and five years , respectively , after the beginning of the Campaign ) . Overall , we recorded a favourable trend in eating habits in both sexes ; a significant decrease in LDL-cholesterol in males , and in systolic and diastolic blood pressure in both sexes ; a non- significant decrease in prevalence of smokers among males and increase among females . The ATS-Sardegna Campaign was the first CVD prevention programme in Italy to have attained reduction in the risk profile of an entire region at the lowest ever borne cost PURPOSE We wanted to determine the effect of promoting the effective communication of absolute cardiovascular disease ( CVD ) risk and shared decision making through disseminating a simple decision aid for use in family practice consultations . METHODS The study was based on a pragmatic , cluster r and omized controlled trial ( phase III ) with  continuing medical education ( CME ) groups of family physicians  as the unit of r and omization . In the intervention arm , 44 physicians ( 7 CME groups ) consecutively recruited 550 patients in whom cholesterol levels were measured . Forty-seven physicians in the control arm ( 7 CME groups ) similarly included 582 patients . Four hundred sixty patients ( 83.6 % ) of the intervention arm and 466 patients ( 80.1 % ) of the control arm were seen at follow-up . Physicians attended 2 interactive CME sessions and received a booklet , a paper-based risk calculator , and individual summary sheets for each patient . Control physicians attended 1 CME-session on an alternative topic . Main outcome measures were patient satisfaction and participation after the index consultation , change in CVD risk status , and decisional regret at 6 months ’ follow-up . RESULTS Intervention patients were significantly more satisfied with process and result ( Patient Participation Scale , difference 0.80 , P<.001 ) . Decisional regret was significantly lower at follow-up ( difference 3.39 , P = .02 ) . CVD risk decreased in both groups without a significant difference between study arms . CONCLUSION A simple transactional decision aid based on calculating absolute individual CVD risk and promoting shared decision making in CVD prevention can be disseminated through CME groups and may lead to higher patient satisfaction and involvement and less decisional regret , without negatively affecting global CVD risk Objectives : The SCORE model predicts the ten-year risk of cardiovascular mortality but it is still unknown whether applying the SCORE in clinical practice subsequently improves cardiovascular disease ( CVD ) outcomes . The objective of this study is to assess the effect of total cardiovascular risk estimation using the SCORE in preventing serious cardiovascular events in European adults without prior CVD . Methods and results : Data sources : eight bibliographical data bases ( 2003 – August 2015 ) , other internet sources and reference lists of articles were checked . This was supplemented by contact with the board members of the European Society of Cardiology ( ESC ) and the authors of the SCORE model . Study eligibility criteria : all prospect i ve studies in any language investigating the effect of using the SCORE on the clinical outcome ( CVD death , major events and adverse outcomes ) in an adult population were examined . Two review ers assessed the studies independently ( titles , abstract s , full texts ) . After removal of duplicates , 5,256 records were screened and 14 full text papers considered . No eligible studies were identified . An extensive literature search revealed no r and omized control trial or other prospect i ve study comparing significant clinical outcomes between groups that used the SCORE and those who did not . Conclusions : The effect of using the SCORE ( with or without subsequent intervention ) on CVD death , all-cause mortality , major CVD events like myocardial infa rct ion and stroke , as well as adverse outcomes , is still unknown . A cluster r and omised controlled trial is warranted to evaluate the use of the SCORE on important outcomes Background High blood pressure ( HBP ) is a major risk factor for cardiovascular disease ( CVD ) . European hypertension and cardiology societies as well as expert committees on CVD prevention recommend stratifying cardiovascular risk using the SCORE method , the modification of lifestyles to prevent CVD , and achieving good control over risk factors . The EDUCORE ( Education and Coronary Risk Evaluation ) project aims to determine whether the use of a cardiovascular risk visual learning method - the EDUCORE method - is more effective than normal clinical practice in improving the control of blood pressure within one year in patients with poorly controlled hypertension but no background of CVD ; Methods / Design This work describes a protocol for a clinical trial , r and omised by clusters and involving 22 primary healthcare clinics , to test the effectiveness of the EDUCORE method . The number of patients required was 736 , all between 40 and 65 years of age ( n = 368 in the EDUCORE and control groups ) , all of whom had been diagnosed with HBP at least one year ago , and all of whom had poorly controlled hypertension ( systolic blood pressure ≥ 140 mmHg and /or diastolic ≥ 90 mmHg ) . All personnel taking part were explained the trial and trained in its methodology . The EDUCORE method contemplates the visualisation of low risk SCORE scores using images embodying different stages of a high risk action , plus the receipt of a pamphlet explaining how to better maintain cardiac health . The main outcome variable was the control of blood pressure ; secondary outcome variables included the SCORE score , therapeutic compliance , quality of life , and total cholesterol level . All outcome variables were measured at the beginning of the experimental period and again at 6 and 12 months . Information on sex , age , educational level , physical activity , body mass index , consumption of medications , change of treatment and blood analysis results was also recorded ; Discussion The EDUCORE method could provide a simple , inexpensive means of improving blood pressure control , and perhaps other health problems , in the primary healthcare setting ; Trial registration The trial was registered with Clinical Trials.gov , number NCT01155973 [ http:// Clinical Trials.gov ] BACKGROUND Cardiovascular disease ( CVD ) is the leading cause of death , and principal reason for the large difference in life expectancy between indigenous Māori and the non-indigenous population in New Zeal and . CVD guidelines recommend that people who are at high risk or who have had previous CVD should be offered aspirin , blood pressure lowering and lipid lowering therapies . However , prescribing and adherence rates are low and CVD events remain high . AIM To assess whether a medication strategy using a fixed dose combination pill ( ' polypill ' ) could improve prescribing and adherence to recommended medications , lower blood pressure and improve lipids compared with current care over 12 months . METHODS IMProving Adherence using Combination Therapy ( IMPACT ) is an open-label r and omised controlled trial comparing a once-daily polypill containing four preventive medications with usual care .  Six hundred participants who have had previous CVD events or are at high risk of CVD will be enrolled , including 300 Māori . Participants are identified , enrolled and prescribed either the polypill or current medications at their usual primary health care practice , with medications ( including the polypill ) dispensed through local community pharmacies . The polypill contains 75 mg aspirin , 40 mg simvastatin , 10 mg lisinopril and either 12.5 mg hydrochlorothiazide or 50 mg atenolol . Primary outcomes are adherence to guidelines -recommended medications and changes in systolic blood pressure and low density lipoprotein at 12 months . Secondary outcomes include other lipids , medication dispensing , barriers to adherence , CVD and other serious adverse events , quality of life and prescriber acceptability . The trial is registered with the Australian New Zeal and Clinical Trial Registry ( ACTRN12606000067572 ) We assessed the importance of Streptococcus pneumoniae and immunologic response to 14-valent pneumococcal vaccine in a r and omized ( saline placebo or vaccine ) double-blind pilot study involving 103 patients with chronic obstructive pulmonary disease ( COPD ) .  Antibody titers , the flora of the sputum , respiratory infections or pneumonias , and deaths were monitored . The patients ' antibody titers before immunization were higher than healthy control subjects . Titers rose normally in those vaccinated but declined more rapidly . Differences between the group receiving placebo and vaccine were not significant at 12 and 24 months . The incidence of pneumonia was high before and after vaccine ( 47/1,000 vs 41/1,000 patient-years ) . Nonpneumococcal causes predominated ( 73 percent of pneumonias ; 83.4 percent of lethal pneumonias ) . Isolates from sputum were predominantly nonvaccine types ( 50 to 62.5 percent ) . Twenty-seven patients died ; pneumonia occurred in six ( one pneumococcal in a vaccinated patient ) as a terminal complication of other diseases . Thus , although pneumonia occurred frequently in these patients with COPD and contributed to mortality in 22 percent ( six ) of the 27 deaths , the predominance of nonpneumococcal causes and the data on antibodies and sputum suggest that pneumococcal vaccine may not be as beneficial for patients with COPD as was hoped . More observations are needed BACKGROUND The identification of persons at high cardiovascular risk is of primary importance in the context of cardiovascular prevention . Accuracy and precision of risk assessment are essential properties . We developed a calibrated SCORE risk chart ( Systematic COronary Risk Evaluation ) for calculating the absolute 10-year probability of developing a fatal cardiovascular event , adapted to national mortality statistics and risk factor distributions in Belgium and critically evaluated its predictive accuracy . METHODS Our SCORE Belgium risk chart was vali date d using data from 6212 non-diabetic men and women free of CHD participating in a prospect i ve cohort study carried out in the eighties ( Belgian Interuniversity Research on Nutrition and Health ) . Agreement between numbers of predicted and observed CVD deaths across the entire spread of risk was studied using chi-square and Hosmer-Lemeshow statistics . Discriminatory power of risk estimates was evaluated according to Harrell 's c-statistic . RESULTS During the period of 10 years , 274 CVD deaths were observed while the recalibrated risk chart predicted 263 events . The SCORE Belgium risk chart showed very good accuracy over the complete range of predicted risk ( Hosmer-Lemeshow : P=0.14 ) . ROC analysis revealed excellent discriminatory power in labelling future cases of fatal cardiovascular disease with a c-statistic of 0.86 . The 5 % threshold for the probability of 10-year cardiovascular death yielded an optimal balance of sensitivity and specificity . CONCLUSIONS The SCORE Belgium risk chart proves to be well suited as an accurate and precise estimation tool for the assessment of cardiovascular risk in Belgium BACKGROUND Despite the cardiovascular disease ( CVD ) risk associated with hypertension , diabetes , dyslipidemia , and smoking , these risk factors remain poorly identified and controlled . OBJECTIVES The study sought to evaluate the effectiveness of a community pharmacy-based case finding and intervention on cardiovascular risk . METHODS The RxEACH ( Alberta Vascular Risk Reduction Community Pharmacy Project ) study was a r and omized trial conducted in 56 community pharmacies . Participants were recruited by their pharmacist , who enrolled adults at high risk for CVD . Patients were r and omized to usual care ( usual pharmacist care with no specific intervention ) or intervention , comprising a Medication Therapy Management review from their pharmacist and CVD risk assessment and education . Pharmacists prescribed medications and ordered laboratory tests as per their scope of practice to achieve treatment targets . Subjects received monthly follow-up visits for 3 months . The primary outcome was difference in change in estimated CVD risk between groups at 3 months . CVD risk was estimated using the greater of the Framingham , International , or United Kingdom Prospect i ve Diabetes Study risk scores . RESULTS We enrolled 723 patients ( mean 62 years of age ; 58 % male , and 27 % smokers ) . After adjusting for baseline values and center effect , there was a 21 % difference in change in risk for CVD events ( p < 0.001 ) between the intervention and usual care groups . The intervention group had greater improvements in low-density lipoprotein cholesterol ( -0.2 mmol/l ; p < 0.001 ) , systolic blood pressure ( -9.37 mm Hg ; p < 0.001 ) , glycosylated hemoglobin ( -0.92 % ; p < 0.001 ) , and smoking cessation ( 20.2 % ; p = 0.002 ) . CONCLUSIONS The RxEACH study was the first large r and omized trial of CVD risk reduction by community pharmacists , demonstrating a significant reduction in risk for CVD events . Engagement of community pharmacists with an exp and ed scope of practice could have significant public health implication s. ( The Alberta Vascular Risk Reduction Community Pharmacy Project : RxEACH [ RxEACH ] ; NCT01979471 ) IMPORTANCE The value of measuring levels of glycated hemoglobin ( HbA1c ) for the prediction of first cardiovascular events is uncertain . OBJECTIVE To determine whether adding information on HbA1c values to conventional cardiovascular risk factors is associated with improvement in prediction of cardiovascular disease ( CVD ) risk . DESIGN , SETTING , AND PARTICIPANTS Analysis of individual-participant data available from 73 prospect i ve studies involving 294,998 participants without a known history of diabetes mellitus or CVD at the baseline assessment . MAIN OUTCOMES AND MEASURES Measures of risk discrimination for CVD outcomes ( eg , C-index ) and reclassification ( eg , net reclassification improvement ) of participants across predicted 10-year risk categories of low ( < 5 % ) , intermediate ( 5 % to < 7.5 % ) , and high ( ≥ 7.5 % ) risk . RESULTS During a median follow-up of 9.9 ( interquartile range , 7.6 - 13.2 ) years , 20,840 incident fatal and nonfatal CVD outcomes ( 13,237 coronary heart disease and 7603 stroke outcomes ) were recorded . In analyses adjusted for several conventional cardiovascular risk factors , there was an approximately J-shaped association between HbA1c values and CVD risk . The association between HbA1c values and CVD risk changed only slightly after adjustment for total cholesterol and triglyceride concentrations or estimated glomerular filtration rate , but this association attenuated somewhat after adjustment for concentrations of high-density lipoprotein cholesterol and C-reactive protein . The C-index for a CVD risk prediction model containing conventional cardiovascular risk factors alone was 0.7434 ( 95 % CI , 0.7350 to 0.7517 ) . The addition of information on HbA1c was associated with a C-index change of 0.0018 ( 0.0003 to 0.0033 ) and a net reclassification improvement of 0.42 ( -0.63 to 1.48 ) for the categories of predicted 10-year CVD risk . The improvement provided by HbA1c assessment in prediction of CVD risk was equal to or better than estimated improvements for measurement of fasting , r and om , or postload plasma glucose levels . CONCLUSIONS AND RELEVANCE In a study of individuals without known CVD or diabetes , additional assessment of HbA1c values in the context of CVD risk assessment provided little incremental benefit for prediction of CVD risk
There is uncertainty whether current strategies for providing CVD risk scores  affect CVD events .
Providing CVD risk scores may slightly reduce CVD risk factor levels and may increase preventive medication prescribing in higher-risk people without evidence of harm .
BACKGROUND The current paradigm for cardiovascular disease ( CVD ) emphasises absolute risk assessment to guide treatment decisions in primary prevention .
Although the derivation and validation of multivariable risk assessment tools , or CVD risk scores , have attracted considerable attention , their effect on clinical outcomes is uncertain .
OBJECTIVES To assess the effects of evaluating and providing CVD risk scores in adults without prevalent CVD on cardiovascular outcomes , risk factor levels , preventive medication prescribing , and health behaviours .