A pharmacist-led follow-up program for patients with established coronary heart disease in North Norway – a randomized controlled trial Is a targeted and planned GP intervention effective in cardiovascular disease prevention? A randomized controlled trial Study protocol for a randomized controlled trial: the feasibility and impact of cardiovascular absolute risk assessment in Australian general practice. The systematic coronary risk evaluation (SCORE) for the prevention of cardiovascular diseases. Does evidence exist for its effectiveness? A systematic review Evaluation of a toolkit to improve cardiovascular disease screening and treatment for people with type 2 diabetes: protocol for a cluster-randomized pragmatic trial Randomized controlled trial on cardiovascular risk management by practice nurses supported by self-monitoring in primary care Individualised multifactorial lifestyle intervention trial for high-risk cardiovascular patients in primary care. Access site practice and procedural outcomes in relation to clinical presentation in 439,947 patients undergoing percutaneous coronary intervention in the United kingdom. Outcomes of Combined Cardiovascular Risk Factor Management Strategies in Type 2 Diabetes: The ACCORD Randomized 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 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 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 Dader Method for pharmaceutical care on control of blood pressure and total cholesterol in outpatients with cardiovascular disease or cardiovascular risk: EMDADER-CV randomized controlled trial. Secondary prevention of cardiovascular disease: a randomised trial of training in information management, evidence-based medicine, both or neither: the PIER trial. Sustaining cardiovascular absolute risk management in Australian general practice. Mixed methods evaluation of targeted case finding for cardiovascular disease prevention using a stepped wedged cluster RCT Randomised controlled trial of two advanced and extended cardiac rehabilitation programmes
Objectives : The aim of the study was twofold ; 1 ) to develop a clinical pharmacist-led 12 month lasting follow-up program for patients with established coronary heart disease ( CHD ) discharged from the University Hospital of North Norway , and 2 ) to explore the impact of the program with regards to adherence to a medication assessment tool for secondary prevention of CHD and change in biomedical risk factors . Methods : A total of 102 patients aged 18 - 82 years were enrolled in a non-blinded r and omized controlled trial with an intervention group and a control group . The intervention comprised medication reconciliation , medication review and patient education during three meetings ; at discharge , after three months and after twelve months . The control group received st and ard care from their general practitioner . Primary outcomes were adherence to clinical guideline recommendations concerning prescription , therapy goal achievement and lifestyle education  defined in the medication assessment tool for secondary prevention of CHD ( MAT-CHDSP ) . Secondary outcomes included changes in the biomedical risk factors cholesterol , blood pressure and blood glucose . Results : Ninety-four patients completed the trial , 48 intervention group patients and 46 controls . Appropriate prescribing was high , but therapy goal achievement was low in both groups . Overall adherence to MAT-CHDSP criteria increased in both groups and was significantly higher in the intervention group at study end , 78.4 % vs. 62.0 % , p<0.001 . The difference was statistically significant for the documented lifestyle advices in intervention group patients . No significant improvements in biomedical risk factors were observed in favor of the intervention group . Conclusions : The study showed an increased guideline adherence in both study groups . This indicates that attention to clinical practice guideline recommendations in itself increases adherence – which may be a clinical pharmacist task . A larger adequately powered study is needed to show a significant difference in biomedical risk factor improvements in favor of the intervention . Amendments to the follow-up program are suggested before implementation in st and ard patient care can be recommended Background The optimal intensity and duration of the intervention to achieve sustained risk reduction in patients at high and very high cardiovascular ( CV ) risk still need to be established . The aim of this study was to evaluate the impact of general practitioner ’s ( GP ’s ) systematic and planned intervention on total CV risk reduction and a change in individual CV risk factors . Material / Methods This was a cluster-r and omized trial ( IS RCT N31857696 ) including 64 practice s and 3245 patients aged ≥40 . The participating GPs and their examinees were r and omized into an intervention or to a control group ( st and ard care ) . Intervention group practitioners followed up their examinees during 1 , 3 , 6 , 12 , and 18 months . The main outcome measures were change in proportion of patients with low , moderate , high , and very high CV risk , and change in individual CV risk factors from the first to the second registration . Results The proportion of patients with very high CV risk was lower in the intervention group , the same as of patients with high blood pressure , total and LDL cholesterol , and increased intake of alcohol . The mean systolic ( −1.49 mmHg ) and diastolic ( −1.57 mmHg ) blood pressure , triglycerides ( −0.18 mmol/L ) , body mass index ( −0.22 ) , and waist ( −0.4 cm ) and hip circumference ( −1.08 cm ) was reduced significantly in the intervention group . There was no additional impact in the intervention group of other tested CV risk factors . Conclusions Systematic and planned GP ’s intervention in CVD prevention reduces the number of patients with very high total CV risk and influences a change in lifestyle habits BACKGROUND Although cardiovascular absolute risk ( CVAR ) assessment has been recommended for use in Australian general practice for a number of years , there is continuing uncertainty about its implementation and impact . Our previous work has developed a multifaceted implementation model . This study aims to investigate both the feasibility of using this model and the impact of CVAR assessment and management on general practice clinical processes and patient care . STUDY DESIGN This cluster r and omized controlled trial will be conducted in general practice s in Sydney , involving general practitioners ( GPs ) , other practice staff , and patients aged 45 to 69 years without existing cardiovascular disease . METHODS A total of 32 practice s ( 40 GPs ) and 1,320 patients will be recruited . R and omization will be conducted at the practice level . The intervention group of GPs will be trained to use a CVAR implementation model , whereas the control group of GPs will continue usual care . Study outcomes include clinical processes , patient risk , use of lifestyle intervention , and prescription of antihypertensive and lipid-lowering medications .  Data will be collected and analyzed using mixed methods . Study outcomes before and after the intervention will be compared , and the 2 groups will also be compared after adjusting for baseline difference and clustering factors . DISCUSSION This trial will be the first study in Australian general practice and one of few international studies to evaluate the impact of implementing CVAR assessment and management . Results of this study will help improve the primary prevention of cardiovascular disease and inform guidelines for clinical practice and the implementation of other health initiatives 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 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 # Background Treatment goals for cardiovascular risk management are generally not achieved . Specialized practice nurses are increasingly facilitating the work of general practitioners and self-monitoring devices have been developed as counseling aid . The aim of this study was to compare st and ard treatment supported by self-monitoring with st and ard treatment without self-monitoring , both conducted by practice nurses , on cardiovascular risk and separate risk factors . Methods Men aged 50–75 years and women aged 55–75 years without a history of cardiovascular disease or diabetes , but with a SCORE 10-year risk of cardiovascular mortality ≥5 % and at least one treatable risk factor ( smoking , hypertension , lack of physical activity or overweight ) , were r and omized into two groups . The control group received st and ard treatment according to guidelines , the intervention group additionally received pro-active counseling and self-monitoring ( pedometer , weighing scale and / or blood pressure device ) . After one year treatment effect on 179 participants was analyzed . Results SCORE risk assessment decreased 1.6 % ( 95 % CI 1.0–2.2 ) for the control group and 1.8 % ( 1.2–2.4 ) for the intervention group , difference between groups was .2 % ( −.6–1.1 ) . Most risk factors tended to improve in both groups . The number of visits was higher and visits took more time in the intervention group ( 4.9 ( SD2.2 ) vs. 2.6 ( SD1.5 ) visits p < .001 and 27 ( P25 –P75:20–33 ) vs. 23 ( P25 –P75:19–30 ) minutes/visit p = .048 ) . Conclusions In both groups cardiovascular risk decreased significantly after one year of treatment by practice nurses . No additional effect of basing the pro-active counseling on self-monitoring was found , despite the extra time investment . Trial registration trialregister.nl BACKGROUND The multiprofessional teams in Finnish health centres are well placed to carry out interventions aim ed at the prevention of cardiovascular diseases . AIM To evaluate the effectiveness of an individually tailored multifactorial lifestyle intervention in primary care for individuals at high risk for cardiovascular disease . DESIGN OF STUDY A r and omised controlled trial was conducted over 24 months with interim assessment s at six and 12 months . SETTING A health centre in Finl and with a patient population of 11,000 . METHOD One hundred and fifty adults aged 18 to 65 years old with existing cardiovascular disease or multiple risk factors were r and omised to active multiprofessional risk factor intervention or to st and ard care . The main outcome measure was a change in cardiovascular risk-factor score . Secondary outcomes were changes in blood pressure , weight , body-mass index , serum cholesterol , blood glucose , smoking cessation , and exercise habits . RESULTS The cardiovascular risk score decreased by 28 % in the intervention group ( 23 % in the control group ) , body weight decreased by 3.7 % ( 2 % ) and total cholesterol decreased by 10.8 % ( 6.5 % ) , while time engaged in exercise increased by 39 % ( 43 % ) . Differences were not significant . CONCLUSIONS Cardiovascular risk levels of high-risk individuals decreased in both intervention and control groups . Primary care prevention should be targeted to high-risk persons . Long-term follow-up studies are needed OBJECTIVES This study sought to determine the relationships among access site practice , clinical presentation , and procedural outcomes in a large patient population . BACKGROUND Transradial access ( TRA ) has been associated with improved patient outcomes in selected population s in r and omized trials . It is unclear whether these outcomes are achievable in clinical practice . METHODS Using the BCIS ( British Cardiovascular Intervention Society ) data base , we investigated outcomes for  percutaneous coronary intervention procedures undertaken between 2007 and 2012 according to access site practice . Patients were categorized as stable , non-ST-segment elevation acute coronary syndrome ( NSTEACS ) and ST-elevation acute coronary syndrome ( STEACS ) . The impact of access site on 30-day mortality , major adverse cardiac events , bleeding , and arterial access site complications was studied . RESULTS Data from 210,260 TRA and 229,687 transfemoral access procedures were analyzed . Following multivariate analysis , TRA was independently associated with a reduction in bleeding in all presenting syndromes ( stable odds ratio [ OR ] : 0.24 , p < 0.001 ; NSTEACS OR : 0.35 , p < 0.001 ; STEACS OR : 0.47 , p < 0.001 ) as well as access site complications ( stable OR : 0.21 , p < 0.001 ; NSTEACS OR : 0.19 ; STEACS OR : 0.16 , p < 0.001 ) . TRA was associated with reduced major adverse cardiac events only in patients with unstable syndromes ( stable OR : 1.08 , p = 0.25 ; NSTEACS OR : 0.72 , p < 0.001 ; STEACS OR : 0.70 , p < 0.001 ) . TRA was associated with improved outcomes compared with a transfemoral access ( TFA ) with a vascular closure device in a propensity matched cohort . CONCLUSIONS In this large study , TRA is associated with reduced percutaneous coronary intervention-related complications in all patient groups and may reduce major adverse cardiac events and mortality in ACS patients . TRA is superior to transfemoral access with closure devices . Use of TRA may lead to important patient benefits in routine practice . TRA should be considered the preferred access site for percutaneous coronary intervention OBJECTIVE To compare effects of combinations of st and ard and intensive treatment of glycemia and either blood pressure ( BP ) or lipids in the Action to Control Cardiovascular Risk in Diabetes ( ACCORD ) trial . RESEARCH DESIGN AND METHODS ACCORD enrolled 10,251 type 2 diabetes patients aged 40–79 years at high risk for cardiovascular disease ( CVD ) events . Participants were r and omly assigned to hemoglobin A1c goals of < 6.0 % ( < 42 mmol/mol ; intensive glycemia ) or 7.0–7.9 % ( 53–63 mmol/mol ; st and ard glycemia ) and then r and omized a second time to either 1 ) systolic BP goals of < 120 mmHg ( intensive BP ) or < 140 mmHg ( st and ard BP ) or 2 ) simvastatin plus fenofibrate ( intensive lipid ) or simvastatin plus placebo ( st and ard lipid ) . Proportional hazards models were used to assess combinations of treatment assignments on the composite primary ( deaths due to CVD , nonfatal myocardial infa rct ion [ MI ] , and nonfatal stroke ) and secondary outcomes . RESULTS In the BP trial , risk of the primary outcome was lower in the groups intensively treated for glycemia ( hazard ratio [ HR ] 0.67 ; 95 % CI 0.50–0.91 ) , BP ( HR 0.74 ; 95 % CI 0.55–1.00 ) , or both ( HR 0.71 ; 95 % CI 0.52–0.96 ) compared with combined st and ard BP and glycemia treatment . For secondary outcomes , MI was significantly reduced by intensive glycemia treatment and stroke by intensive BP treatment ; most other HRs were neutral or favored intensive treatment groups . In the lipid trial , the general pattern of results showed no evidence of benefit of intensive regimens ( whether single or combined ) compared with combined st and ard lipid and glycemia treatment . The mortality HR was 1.33 ( 95 % CI 1.02–1.74 ) in the st and ard lipid/intensive glycemia group compared with the st and ard lipid/st and ard glycemia group . CONCLUSIONS In the ACCORD BP trial , compared with combined st and ard treatment , intensive BP or intensive glycemia treatment alone improved major CVD outcomes , without additional benefit from combining the two . In the ACCORD lipid trial , neither intensive lipid nor glycemia treatment produced an overall benefit , but intensive glycemia treatment increased mortality 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 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 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 BACKGROUND Although some studies have demonstrated that pharmacist intervention can improve drug therapy among patients with cardiovascular disease ( CVD ) , more evidence derived from r and omized controlled trials ( RCTs ) is needed , including assessment of the effect of community pharmacist interventions in patients with CVD . OBJECTIVE To assess the effectiveness of the Dader Method for pharmaceutical care on achieving therapeutic goals for blood pressure ( BP ) , total cholesterol ( TC ) , and both BP and TC ( BP/TC ) in patients with CVD and /or high or intermediate cardiovascular ( CV ) risk attending community pharmacies in Spain . METHODS Patients aged 25 to 74 years attending community pharmacies with a prescription for at least 1 drug indicated for CVD or CV risk factors were r and omized to 2 groups : an intervention group that received pharmaceutical care , which was provided by specially trained pharmacists working in collaboration with physicians , and a control group that received usual care ( routine dispensing counseling ) and verbal and written counseling regarding CVD prevention .  Patients were recruited from December 2005 to September 2006 , and both groups were followed for 8 months . Study outcomes were assessed at baseline and at 16 and 32 weeks after r and omization . The primary outcome measures were the proportions of patients achieving BP , TC , and BP/TC therapeutic goals ( BP lower than 140/90 mm Hg for patients with uncomplicated hypertension and lower than 130/80 mm Hg for patients with diabetes , chronic kidney disease , or history of myocardial infa rct ion or stroke ; TC lower than 200 mg per dL for patients without CVD and lower than 175 mg per dL for patients with CVD ) . Secondary outcomes were mean BP and TC values . BP was assessed manually by the pharmacist after a 10-minute rest in the supine position . This measurement was performed twice for every participant , and the average of the 2 measurements was calculated . TC was measured by the pharmacist during the study visit using the enzymatic dry method . Statistical analyses were performed using 2-tailed McNemar tests , Pearson chi-square tests , and Student 's t-tests ; P < 0.05 was considered statistically significant . RESULTS 714 patients were included in the study ( 356 intervention , 358 control ) , and the mean [ SD ] age was 62.8 [ 8.1 ] years . The 2 groups were similar at baseline in clinical and demographic characteristics , including the proportion of patients at therapeutic goals for BP , TC , and BP/TC . After 8 months of follow-up , there were statistically significant differences in favor of pharmaceutical care in the proportions of patients who achieved therapeutic goals for BP ( 52.5 % vs. 43.0 % , P=0.017 ) , TC ( 56.5 % vs. 44.1 % , P=0.001 ) , and BP/TC ( 37.1 % vs. 21.8 % , P < 0.001 ) . CONCLUSION Compared with usual care plus written education , pharmaceutical care focused on patient evaluation and follow-up in collaboration with physicians improved the achievement of BP , TC , and BP/TC treatment goals in patients with CVD and /or high or intermediate CV risk attending community pharmacies in Spain 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 This study describes the attitudes and practice s of patients and GPs 12 months after participating in a trial of absolute cardiovascular risk assessment in general practice . It involved a qualitative design using semistructured interviews with 12 Sydney GPs from the intervention arm of a cluster r and omised controlled trial of cardiovascular absolute risk ( CVAR ) assessment and 15 of their moderate to high risk patients who participated in the assessment s. Most GPs had sustained CVAR assessment in their practice , using it primarily to motivate patients to change their behaviour and adhere to management rather than to make decisions about pharmacotherapy or referral . Time was a barrier to its use . Patients who sustained changes to their behaviour had internalised the benefits to their health and received support from family and friends . Those who relapsed attributed this to their own lack of motivation and extrinsic factors . CVAR assessment needs to be incorporated into practice information systems and long-term planned preventive care if it is to be sustained in general practice and have long-term impacts on patient behaviour Background A pilot project cardiovascular prevention was implemented in S and well ( West Midl and s , UK ) . This used electronic primary care records to identify untreated patients at high risk of cardiovascular disease then invited these high risk patients for assessment by a nurse in their own general practice . Those found to be eligible for treatment were offered treatment . During the pilot a higher proportion of high risk patients were started on treatment in the intervention practice s than in control practice s. Following the apparent success of the prevention project , it was intended to extend the service to all practice s across the S and well area . However the pilot project was not a robust evaluation . There was a need for an efficient evaluation that would not disrupt the planned rollout of the project . Methods / design Project nurses will sequentially implement targeted cardiovascular case finding in a phased way across all general practice s , with the sequence of general practice s determined r and omly . This is a stepped wedge r and omised controlled trial design . The target population is patients aged 35 to 74 , without diabetes or cardiovascular disease whose ten-year cardiovascular risk , ( determined from data in their electronic records ) is ≥20 % . The primary outcome is the number of high risk patients started on treatment , because these data could be efficiently obtained from electronic primary care records . From this we can determine the effects of the case finding programme on the proportion of high risk patients started on treatment in practice s before and after implementation of targeted case finding . Cost-effectiveness will be modelled from the predicted effects of treatments on cardiovascular events and associated health service costs . Alongside the implementation it is intended to interview clinical staff and patients who participated in the programme in order to determine acceptability to patients and clinicians . Practical considerations meant that 26 practice s in S and well could be r and omised , including about 6,250 patients at high risk of cardiovascular disease . This gives sufficient power for evaluation . Discussion It is possible to design a stepped wedge r and omised controlled trial using routine data to determine the primary outcome to evaluate implementation of a cardiovascular prevention programme Objective The OPTICARE ( OPTImal CArdiac REhabilitation ) r and omised controlled trial compared two advanced and extended cardiac rehabilitation ( CR ) programmes to st and ard CR for patients with acute coronary syndrome ( ACS ) . These programmes were design ed to stimulate permanent adoption of a heart-healthy lifestyle . The primary outcome was the SCORE ( Systematic COronary Risk Evaluation ) 10-year cardiovascular mortality risk function at 18 months follow-up . Methods In total , 914 patients with ACS ( age , 57 years ; 81 % men ) were r and omised to : ( 1 ) 3 months st and ard CR ( CR-only ) ; ( 2 ) st and ard CR including three additional face-to-face active lifestyle counselling sessions and extended with three group fitness training and general lifestyle counselling sessions in the first 9 months after st and ard CR ( CR+F ) ; or ( 3 ) st and ard CR extended for 9 months with five to six telephone general lifestyle counselling sessions ( CR+T ) . Results In an intention-to-treat analysis , we found no difference in the SCORE risk function at 18 months between CR+F and CR-only ( 3.30 % vs 3.47 % ; p=0.48 ) , or CR+T and CR-only ( 3.02 % vs 3.47 % ; p=0.39 ) . In a per- protocol analysis , two of three modifiable SCORE parameters favoured CR+F over CR-only : current smoking ( 13.4 % vs 21.3 % ; p<0.001 ) and total cholesterol ( 3.9 vs 4.3 mmol/L ; p<0.001 ) . The smoking rate was also lower in CR+T compared with the CR-only ( 12.9 % vs 21.3 % ; p<0.05 ) . Conclusions Extending CR with extra behavioural counselling ( group sessions or individual telephone sessions ) does not confer additional benefits with respect to SCORE parameters . Patients largely reach target levels for modifiable risk factors with few hospital readmissions already following st and ard CR . Trial registration number Clinical Trials.gov NCT01395095 ; results
The impact of TRA on global CVD risk as well as individual risk factors is ambiguous , but a tendency towards slight reduction of blood pressure , total cholesterol and smoking levels , especially in high risk patient groups was observed .
TRA had no influence on lifestyle behaviour .
Conclusions There is limited evidence , of low overall quality , suggesting a possible lack of effectiveness of TRA in reducing CVD events and mortality , as well as a clinical ly insignificant influence on individual risk factor levels .
Background Our objectives were to critically appraise and summarise the current evidence for the effectiveness of using cardiovascular disease ( CVD ) risk scoring ( total risk assessment - TRA ) in routine risk assessment in primary prevention of CVD compared with st and ard care with regards to patients outcomes , clinical risk factor levels , medication prescribing , and adverse effects .