Digital health intervention during cardiac rehabilitation: A randomized controlled trial Improving diabetes care: multi-component cardiovascular disease risk reduction strategies for people with diabetes in South Asia--the CARRS multi-center translation trial. A cardiovascular disease policy model that predicts life expectancy taking into account socioeconomic deprivation The effect of gender on outcome in digitalis-treated heart failure patients. Improvements in 1-Year Cardiovascular Clinical Outcomes Associated with a Hospital-Based Discharge Medication Program Cost-Effectiveness of the Diabetes Care Protocol, a Multifaceted Computerized Decision Support Diabetes Management Intervention That Reduces Cardiovascular Risk Evaluating the use of mobile phone technology to enhance cardiovascular disease screening by community health workers The impact of individualised cardiovascular disease (CVD) risk estimates and lifestyle advice on physical activity in individuals at high risk of CVD: a pilot 2 × 2 factorial understanding risk trial The South Asian Heart Lifestyle Intervention (SAHELI) study to improve cardiovascular risk factors in a community setting: design and methods. Designing an Internet-Based Multidomain Intervention for the Prevention of Cardiovascular Disease and Cognitive Impairment in Older Adults: The HATICE Trial. A multifaceted strategy using mobile technology to assist rural primary healthcare doctors and frontline health workers in cardiovascular disease risk management: protocol for the SMARTHealth India cluster randomised controlled trial ESTIMATING THE RISK OF CARDIO VASCULAR DISEASES AMONG PAKISTANI DIABETICS USING U.K. PDS RISK ENGINE. Effectiveness of a tailored intervention to improve cardiovascular risk management in primary care: study protocol for a randomised controlled trial Association of cardiovascular health screening with mortality, clinical outcomes, and health care cost: a nationwide cohort study. Health-Related Quality of Life Consequences of Implantable Cardioverter Defibrillators: Results From MADIT II Pilot study to determine the impact of a multidisciplinary educational intervention in patients hospitalized with heart failure. Effects on cardiovascular disease risk of a web-based health risk assessment with tailored health advice: a follow-up study
Background Digital health interventions ( DHI ) have been shown to improve intermediates of cardiovascular health , but their impact on cardiovascular ( CV ) outcomes has not been fully explored . The aim of this study was to determine whether DHI administered during cardiac rehabilitation ( CR ) would reduce CV‐related emergency department ( ED ) visits and rehospitalizations in patients after percutaneous coronary intervention ( PCI ) for acute coronary syndrome ( ACS ) . Methods We r and omized patients undergoing CR following ACS and PCI to st and ard CR ( n = 40 ) or CR + DHI ( n = 40 ) for 3 months with 3 patients withdrawing from CR prior to initiation in the treatment arm and 6 in the control group . The DHI incorporated an online and smartphone‐based CR platform asking the patients to report of dietary and exercise habits throughout CR as well as educational information toward patients ' healthy lifestyles . We obtained data regarding ED visits and rehospitalizations at 180 days , as well as other metrics of secondary CV prevention at baseline and 90 days . Results Baseline demographics were similar between the groups . The DHI + CR group had improved weight loss compared to the control group ( −5.1 ± 6.5 kg vs. −0.8 ± 3.8 kg , respectively , P = .02 ) . Those in the DHI + CR group also showed a non‐significant reduction in CV‐related rehospitalizations plus ED visits compared to the control group at 180 days ( 8.1 % vs 26.6 % ; RR 0.30 , 95 % CI 0.08‐1.10 , P = .054 ) . Conclusions The current study demonstrated that complementary DHI  significantly improves weight loss , and might offer a method to reduce CV‐related ED visits plus rehospitalizations in patients after ACS undergoing CR . The study suggests a role for DHI as an adjunct to CR to improve secondary prevention of CV disease . Trial registration This trial is registered at clinical trials.gov ( NCT01883050 ) 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 ) Objectives A policy model is a model that can evaluate the effectiveness and cost-effectiveness of interventions and inform policy decisions . In this study , we introduce a cardiovascular disease ( CVD ) policy model which can be used to model remaining life expectancy including a measure of socioeconomic deprivation as an independent risk factor for CVD . Design A state transition model was developed using the Scottish Heart Health Extended Cohort ( SHHEC ) linked to Scottish morbidity and death records . Individuals start in a CVD-free state and can transit to three CVD event states plus a non-CVD death state . Individuals who have a non-fatal first event are then followed up until death . Taking a competing risk approach , the cause-specific hazards of a first event are modelled using parametric survival analysis . Survival following a first non-fatal event is also modelled parametrically . We assessed discrimination , validation and calibration of our model . Results Our model achieved a good level of discrimination in each component ( c-statistics for men (women)—non-fatal coronary heart disease ( CHD ) : 0.70 ( 0.74 ) , non-fatal cerebrovascular disease ( CBVD ) : 0.73 ( 0.76 ) , fatal CVD : 0.77 ( 0.80 ) , fatal non-CVD : 0.74 ( 0.72 ) , survival after non-fatal CHD : 0.68 ( 0.67 ) and survival after non-fatal CBVD : 0.65 ( 0.66 ) ) . In general , our model predictions were comparable with observed event rates for a Scottish r and omised statin trial population which has an overlapping follow-up period with SHHEC . After applying a calibration factor , our predictions of life expectancy closely match those published in recent national life tables . Conclusions Our model can be used to estimate the impact of primary prevention interventions on life expectancy and can assess the impact of interventions on inequalities BACKGROUND The use of digitalis is recommended for the treatment of heart failure to reduce hospitalization . Recent data suggest that digitalis treatment may adversely affect survival in women but not in men . We studied patients with left ventricular dysfunction enrolled in the Studies of Left Ventricular Dysfunction ( SOLVD ) to determine whether there was a gender-based survival difference in patients treated with digitalis .  METHODS AND RESULTS Symptomatic ( n = 2569 ) and asymptomatic ( n = 4228 ) patients with left ventricular ejection fraction < or = 0.35 were studied . Digitalis use was assessed at baseline and baseline demographic variables were catalogued and compared . A multivariate analysis , incorporating known covariates of risk for adverse cardiovascular events , was used to examine the association of digitalis with all-cause mortality , cardiovascular death , death from heart failure , and arrhythmic death , with , or without , worsening heart failure in women compared with men . Analysis for an interaction between digitalis and gender on mortality was also performed . No interaction between gender and digitalis treatment on survival was found , and there was no significant difference in the hazard ratios for men and women on digitalis either with respect to all-cause mortality , cardiovascular mortality , heart failure mortality , or arrhythmic death with worsening heart failure . When mortality for arrhythmic death without worsening heart failure was adjusted for the probability of being treated with digitalis ( propensity analysis ) , women fared better than men . CONCLUSION Data from the SOLVD trials suggest that digitalis treatment of heart failure does not result in a difference in survival between men and women . Because a r and omized trial to definitively answer the question is unlikely , and perhaps inappropriate , examination of other heart failure population s for a gender-digitalis interaction is indicated Context Despite evidence to support the effectiveness of a variety of interventions for the secondary prevention of cardiovascular disease , many eligible patients do not receive these interventions . Contribution Compared with a baseline period , patients hospitalized with cardiovascular disease who received an  intervention that focused on discharge medications had higher rates of prescription of aspirin , -blockers , statins , angiotensin-converting enzyme inhibitors , and warfarin at hospital discharge . The risk for death and readmission was lower in the intervention period than in the baseline period . Caution s The prepost design of this study does not permit conclusions about a causal relationship between the intervention and the observed improvements . The Editors Cardiovascular disease remains the most common source of morbidity and mortality in western countries ( 1 ) . During the past 2 decades , a variety of significant medical advances have been made in the treatment and prevention of complications associated with major cardiovascular disorders , including coronary artery disease , congestive heart failure ( CHF ) , and atrial fibrillation . Many of these advances in secondary prevention relate simply to the appropriate use of certain medications , for example , aspirin and statins for coronary artery disease , -blockers and angiotensin-converting enzyme inhibitors for CHF , and warfarin for prevention of stroke and other embolic events in patients with atrial fibrillation . Each of these medical therapies has been proven in large , multicenter , r and omized , double-blind , placebo-controlled trials to save lives under appropriate circumstances ( 2 - 7 ) . However , despite the overwhelming evidence supporting the benefit of these medications , many studies have documented a significant treatment gap . Often , far fewer than 50 % of potential beneficiaries actually receive treatment ( 8 - 13 ) , and studies from our institution and others have shown that many patients do not receive indicated medications at hospital discharge ( 14 , 15 ) . On the other h and , the chances of long-term adherence are significantly higher when medications are provided at hospital discharge , and this difference is associated with decreased mortality rates ( 13 , 16 ) . Hospital discharge is a critical juncture in the process of care . Patients are available for consultation and are often more disposed to adopt health care recommendations . A hospital dischargebased intervention could be more easily implemented , more effectively managed and measured , and more cost-effective than other potential outpatient intervention strategies . Consequently , there is substantial justification for focusing on hospital discharge as the ideal time to improve prescription of medications for secondary prevention of cardiovascular disease . In the current study , our objectives were to 1 ) determine the feasibility of implementing a comprehensive quality improvement initiative in a large multihospital network to significantly increase rates of prescription at discharge of evidence -based , secondary prevention medications for life-threatening cardiovascular diseases ; 2 ) ascertain the effect of such a program on long-term clinical outcomes ; and 3 ) determine whether good adherence to such an initiative is sustainable . Methods Intermountain Health Care ( IHC ) is a nonprofit , integrated health care system including 20 hospitals , a system of health plans , and both employed and affiliated physicians . The approximately 400 employed physicians mainly practice primary care , and the approximately 2500 affiliated physicians are mostly specialists . Intermountain Health Care serves approximately 60 % of the population of Utah and southern Idaho . The system 's 10 largest hospitals were included in the quality improvement initiative , accounting for more than 90 % of the total population of cardiovascular patients . The major intent of this initiative was to ensure that appropriate secondary prevention medications were prescribed at discharge to all patients ( excluding those with documented contraindications ) who were hospitalized with a principal cardiovascular diagnosis of acute myocardial infa rct ion ( MI ) , coronary heart disease ( CHD ) , CHF , or atrial fibrillation . Table 1 shows the guidelines that were developed for each of the diagnostic categories , and Appendix Figure 1 shows the reference card that was developed to aid physicians and clinical staff . All of the guidelines were based on the current class IA American Heart Association/American College of Cardiology recommendations , except for the recommendation of a statin in all patients with CHD , including those with a low-density lipoprotein cholesterol level less than 2.59 mmol/L ( < 100 mg/dL ) . Our research ( 17 ) showed that a statin provided significant benefit in this population , a notion that has since been supported by a large clinical trial ( 18 ) . -Blocker therapy for patients with CHF was deferred until after discharge . Table 1 . Discharge Medication Guidelines for the Secondary Prevention of Cardiovascular Disorders Design and Implementation of the Quality Improvement Program In 1998 , before the new discharge medication program ( DMP ) was initiated , a new institution-wide data base was developed to assist in its implementation and long-term management . Simultaneously , all participating institutions began prospect ively tracking prescription of applicable discharge medications for all cardiac patients discharged from their respective cardiovascular departments ( Appendix Figure 2 ) . The DMP was implemented on 1 January 1999 , and tracking of discharge prescriptions continued . Maintenance of the discharge medication data base is ongoing , and information through February 2002 was included in this study . Appendix Figure 2 . Data collection form for the discharge medication program . Implementation of the DMP required support and commitment from every level of the health care system , including administration , physicians , nurses , and other staff . To gain this support , the IHC Cardiovascular Clinical Program leadership conducted an extensive education campaign in all participating hospitals . Before the actual initiation of the DMP , this group conducted an extensive tour to engage physicians , residents , and nurses with the program , its goals , and its rationale . The actual DMP implementation and documentation process varied from hospital to hospital but always included the essential core elements . The appropriate indication for each medication was printed directly on the patient discharge form , so physicians needed only to check the correct box or record the specific contraindication ( Appendix Figure 3 ) . This form served as a project management and data collection tool . When an appropriate medication was not prescribed , the discharge-planning nurse contacted the attending physician or resident directly , after which the missing medication could be added to the discharge prescriptions or an appropriate contraindication for its use could be documented . All information was entered into a computerized data base for tracking . Other than the additional re sources for data management , the DMP used existing hospital personnel . No organized effort was made to guarantee long-term adherence to prescribed medications after discharge . Appendix Figure 2 . Discharge orders form .. Documentation of Short-Term Success of the Program To measure and manage the short-term success of the program , monthly reports were generated showing the proportion of cardiovascular patients discharged with prescriptions for the indicated secondary prevention medications at each of the 10 hospitals . These reports were shared extensively with all participating health care providers from each contributing institution in an effort to further increase adherence . Long-Term Follow-up To monitor the effect of DMP implementation on long-term clinical outcomes , the baseline characteristics ( age , sex , and discharge diagnosis ) of each cardiovascular patient discharged from the 10 participating facilities were compiled from the central ized IHC informatics data base . Each patient was followed prospect ively for up to 1 year for hospital readmission due to a cardiovascular indication or for death . If no evidence of hospital readmission or death could be found for a patient , we assumed that the patient had not experienced either event . Information was included from 1996 , 3 years before DMP  initiation , to February 2002 , more than 3 years afterward . Rehospitalizations ( cardiovascular only ) were determined through the IHC informatics system 's electronic data warehouse , and death was ascertained by using the IHC system and the Social Security Administration 's death records . Such electronic follow-up , in our experience ( 16 ) , has proven more thorough and accurate than telephone surveys . Although a limited proportion of patients may have been readmitted to other hospitals for subsequent care , they were probably r and omly distributed between the pre-DMP and DMP sample s. Characteristics of patients admitted before ( 1996 to 1998 ) and after ( 1999 to 2002 ) DMP implementation were evaluated separately and compared . Statistical Analysis The chi-square test was used to evaluate differences in the proportions of patients receiving appropriate discharge prescriptions  in the  pre-DMP and DMP groups . To evaluate the effect of the DMP , we formed 4 mutually exclusive diagnostic or procedural categories for patients with the following index admissions : CHD without CHF , MI , or coronary artery bypass grafting ( CABG ) ; CHF without MI or CABG ; MI without CABG ; and CABG . The category of atrial fibrillation was not mutually exclusive of the other 4 categories . These categories reflected different patient sample s and were not design ed to evaluate groups on the basis of indications for each separate medication , since more than 1 medication could have been indicated in any given patient . Differences between baseline characteristics of the pre-DMP and DMP groups were 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 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 Background There is currently much interest in encouraging individuals to increase physical activity in order to reduce CVD risk . This study has been design ed to determine if personalised CVD risk appreciation can increase physical activity in adults at high risk of CVD . Methods / Design In a 2 × 2 factorial design participants are allocated at r and om to a personalised 10-year CVD risk estimate or numerical CVD risk factor values ( systolic blood pressure , LDL cholesterol and fasting glucose ) and , simultaneously , to receive a brief lifestyle advice intervention targeting physical activity , diet and smoking cessation or not . We aim to recruit 200 participants from Oxfordshire primary care practice s. Eligibility criteria include adults age 40–70 years , estimated 10-year CVD risk ≥20 % , ability to read and write English , no known CVD and no physical disability or other condition reducing the ability to walk . Primary outcome is physical activity measured by ActiGraph accelerometer with biochemical , anthropometrical and psychological measures as additional outcomes . Primary analysis is between group physical activity differences at one month powered to detect a difference of 30,000 total counts per day of physical activity between the groups . Additional analyses will seek to further eluci date the relationship between the provision of risk information , and intention to change behaviour and to determine the impact of both interventions on clinical and anthropometrical measures including fasting and 2 hour plasma glucose , fructosamine , serum cotinine , plasma vitamin C , body fat percentage and blood pressure . Discussion This is a pilot trial seeking to demonstrate in a real world setting , proof of principal that provision of personalised risk information can contribute to behaviour changes aim ed at reducing CVD risk . This study will increase our underst and ing of the links between the provision of risk information and behaviour change and if successful , could be used in clinical practice with little or no modification Disseminating and implementing evidence -based , cardiovascular disease ( CVD ) prevention lifestyle interventions in community setting s and in ethnic minority population s is a challenge . We describe the design and methods for the South Asian Heart Lifestyle Intervention ( SAHELI ) study , a pilot study design ed to determine the feasibility and initial efficacy of a culturally-targeted , community-based lifestyle intervention to improve physical activity and diet behaviors among medically underserved South Asians ( SAs ) . Participants with at least one CVD risk factor will be r and omized to either a lifestyle intervention or a control group .  Participants in both groups will be screened in a community setting and receive a primary care referral after r and omization . Intervention participants will receive 6weeks of group classes , followed by 12weeks of individual telephone support where they will be encouraged to initiate and maintain a healthy lifestyle goal . Control participants will receive their screening results and monthly mailings on CVD prevention . Primary outcomes will be changes in moderate/vigorous physical activity and saturated fat intake between baseline , 3- , and 6-month follow-up . Secondary outcomes will be changes in weight , clinical risk factors , primary care visits , self-efficacy , and social support . This study will be one of the first to pilot-test a lifestyle intervention for SAs , one of the fastest growing racial/ethnic groups in the U.S. and one with disparate CVD risk . Results of this pilot study will provide preliminary data about the efficacy of a lifestyle intervention on CVD risk in SAs and inform community-engaged CVD prevention efforts in an increasingly diverse U.S. population BACKGROUND 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 Background Blood Pressure related disease affected 118 million people in India in the year 2000 ; this figure will double by 2025 . Around one in four adults in rural India have hypertension , and of those , only a minority are accessing appropriate care . Health systems in India face substantial challenges to meet these gaps in care , and innovative solutions are needed . Methods We hypothesise that a multifaceted intervention involving capacity strengthening of primary healthcare doctors and non-physician healthcare workers through use of a mobile device-based clinical decision support system will result in improved blood pressure control for individuals at high risk of a cardiovascular disease event when compared with usual healthcare . This intervention will be implemented as a stepped wedge , cluster r and omised controlled trial in 18 primary health centres and 54 villages in rural And hra Pradesh involving adults aged ≥40 years at high cardiovascular disease event risk ( approximately 15,000 people ) . Cardiovascular disease event risk will be calculated based on World Health Organisation/International Society of Hypertension ’s region-specific risk charts . Cluster r and omisation will occur at the level of the primary health centres . Outcome analyses will be conducted blinded to intervention allocation . Expected outcomes The primary study outcome is the difference in the proportion of people meeting guideline -recommended blood pressure targets in the intervention period vs. the control period . Secondary outcomes include mean reduction in blood pressure levels ; change in other cardiovascular disease risk factors , including body mass index , current smoking , reported healthy eating habits , and reported physical activity levels ; self-reported use of blood pressure and other cardiovascular medicines ; quality of life ( using the EQ-5D ) ; and cardiovascular disease events ( using hospitalisation data ) . Trial outcomes will be accompanied by detailed process and economic evaluations . Significance The findings are likely to inform policy on a scalable strategy to overcome entrenched inequities in access to effective healthcare for under-served population s in low and middle income country setting s . Trial registration Clinical Trial Registry India CTRI/2013/06/003753 BACKGROUND The concept of risk estimation of Coronary Heart Disease ( CHD ) is helpful for clinician to identifying high risk population s for their effective treatment . Latest studies recommended only initiating cardioprotective treatment in diabetic patients based on personalized CHD risk estimates so as to reduce undue harm from overly aggressive risk factor modification . The United Kingdom Prospect i ve Diabetes Study ( UK PDS ) Risk Engine is a widely used tool to assess the risk of Cardio Vascular diseases ( CVD ) in diabetics . The literature search so far did not reveal any study of risk assessment among Pakistani Diabetics . METHODS This descriptive study is based on the data of 470 type-2 diabetics seen in Department of Endocrinology and Metabolism , Services Institute of Medical Sciences , Lahore during 2011 . The data of these 470 patients was analyzed through UKPDS Risk Engine . CHD risk was calculated . RESULTS The 10 years risk of CHD , fatal CHD , stroke and fatal stroke was 9.4 % , 4.4 % , 1.7 % and 0.2 % respectively . CONCLUSIONS The present study show a lower risk of CVD occurring among Pakistani diabetics as compared to studies from western countries 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 : OBJECTIVE To determine whether a  cardiovascular disease ( CVD ) health screening program is associated with CVD-related health conditions , incidence of cardiovascular events , mortality , healthcare utilization , and costs . METHODS Cohort study of a 3 % r and om sample of all Korea National Health Insurance members 40years of age or older and free of CVD or CVD-related health conditions was conducted . A total 443,337 study participants were followed-up from January 1 , 2005 through December 31 , 2010 . RESULTS In primary analysis , the hazard ratios for CVD mortality , all-cause mortality , incident composite CVD events , myocardial infa rct ion , cerebral infa rct ion , and cerebral hemorrhage comparing participants who attended a screening exam during 2003 - 2004 compared to those who did not were 0.58 ( 95 % CI : 0.53 - 0.63 ) , 0.62 ( 95 % CI : 0.60 - 0.64 ) , 0.82 ( 95 % CI : 0.78 - 0.85 ) , 0.84 ( 95 % CI : 0.75 - 0.93 ) , 0.84 ( 95 % CI : 0.79 - 0.89 ) , and 0.73 ( 95 % CI : 0.67 - 0.80 ) , respectively . Screening attenders had higher rates of newly diagnosed hypertension , diabetes mellitus , and dyslipidemia , lower inpatient days of stay and cost , and lower outpatient cost compared to non-attenders . CONCLUSIONS Participation in CVD health screening was associated with lower rates of CVD , all-cause mortality , and CVD events , higher detection of CVD-related health conditions , and lower healthcare utilization and costs Background : Implantable cardioverter defibrillators ( ICDs ) improve survival and extend lives of patients with severe heart disease . Objective : We sought to evaluate the impact of ICDs on health-related quality of life ( HRQOL ) during the first 3 years after implantation . Subjects : A total of 1089 patients from the Multicenter Automatic Defibrillator Implantation Trial II ( MADIT II ) were r and omized to an ICD or medical treatment only . Measures : Health Utility Index ( HUI3 ) at baseline , 3 , 12 , 24 , and 36 months following r and omization ; survival data . Research Design : We constructed mean profiles of HRQOL for living patients , estimated overall quality -adjusted life years ( QALYs ) , separately by treatment arm , and calculated cumulative QALY gains/losses as the difference between the areas under the treatment specific HRQOL profiles . Multivariate fixed effect regression models were developed to impute the missing HRQOL data using baseline patient characteristics ( age , gender , treatment , HUI3 score , diabetes , diuretics use , and NYHA class ) . Bootstrapped st and ard errors were calculated for the estimated differences in HRQOL gains/losses between treatment arms . Similarly , we performed subgroup analyses ( by gender , age , and baseline NYHA class , blood urine nitrogen , ejection fraction , and QRS ) . Results : There were no differences in QALYs loss for living patients by treatment group ( −0.037 , P = 0.64 ) or in overall QALYs loss by treatment group ( 0.043 , P = 0.37 ) over 3 years . In subgroup analysis , female subjects demonstrated a trend towards greater survival benefit ( 0.298 , P = 0.07 ) and overall QALYs ( 0.261 , P = 0.14 ) . Conclusions : Adverse effects of the ICD on HRQOL together with lower HRQOL among survivors may offset the 3-year survival benefits of ICDs BACKGROUND Patients with heart failure ( HF ) face challenges complying with multidrug regimens . OBJECTIVES To examine the impact of a compliance enhancing intervention on medication compliance and morbidity in HF . DESIGN Patients were r and omized to either usual care or an inhospital educational intervention  delivered by a multidisciplinary team ( Intervention ) . SETTING Acute medical and surgical units at a teaching hospital . PATIENTS One hundred thirty four patients with a clinical diagnosis of HF and a left ventricular ejection fraction of < 40 % requiring long-term medical treatment . MAIN OUTCOME MEASURES A vali date d HF-specific instrument provided a measure of knowledge . We characterized patients as noncompliant if pharmacy refill data suggested they had taken < or = 0.80 of their medication . We measured quality of life using the Minnesota Living with Heart Failure Question naire and the Short Form 36 and conducted a time to first event analysis of a composite end point including mortality , readmissions , and emergency department visits . RESULTS The Intervention group showed higher knowledge scores at discharge and 1 year ( P = .05 ) . The risk of noncompliance in Intervention patients varied from 0.78 ( 95 % CI 0.33 - 1.89 ) for ACE-I ( 13 % Intervention , 17 % Control ) to 1.02 ( 0.49 - 2.12 ) for diuretics ( 23 % Intervention , 23 % Control ) . Quality of life improved in both groups over time ; the only difference between groups favored the Intervention ( Minnesota Living with Heart Failure Question naire , P = .04 ) . The composite end point occurred in 67 % of control and 60 % of Intervention patients ( hazard ratio 0.85 , 95 % CI 0.55 - 1.30 ) . CONCLUSIONS An inhospital educational intervention improved knowledge and , possibly , quality of life and may be useful as part of a comprehensive compliance enhancing strategy in patients with HF 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
Overall , these aggregations of data provide evidence that DHIs can reduce CVD outcomes and have a positive impact on risk factors for CVD
OBJECTIVE To assess the potential benefit of digital health interventions ( DHIs ) on  cardiovascular disease ( CVD ) outcomes ( CVD events , all-cause mortality , hospitalizations ) and risk factors compared with non-DHIs .