BACKGROUND:Chronic kidney disease (CKD) is an important risk factor for the progression of coronary artery disease (CAD). OBJECTIVES:The purposes of this study were to quantify the prevalence of CKD in CAD patients from 14 countries from all World Health Organization regions and to evaluate the prognostic value of estimated glomerular filtration rate (eGFR) and urinary albumin/creatinine ratio (UACR). METHODS:A total of 4,548 patients with CAD were included (79.6% were males; age range: 18-80 years). They were assessed for eGFR and UACR 6 to 24 months after the CAD diagnosis. Complete information on kidney function and cardio-renal protective therapy was available for 3,865 patients and follow-up data after a median of 1 year were available for 3,577 (92.5%). RESULTS:CKD according to the Kidney Disease Improving Global Outcomes classification was present in 32% of whom 19.7% were classified as low-moderate, 6.9% as high, and 5.6% as very high risk. Without UACR, 51.3% of them would have been undetected. The primary event, first of cardiovascular death, myocardial infarction, stroke, and hospitalization for heart failure, was observed in 7.9%, with the highest incidence in the Kidney Disease Improving Global Outcomes high-risk group (men: 13.0%; women: 11.8%). This relationship was independent of other risk factors and evident soon after the index examination. Only a minority of the patients received adequate cardio-renal protective therapy. CONCLUSIONS:Early screening for CKD in patients with CAD is important and should preferably include both eGFR and UACR to provide a complete diagnosis. Without UACR, half of those with CKD would remain undetected. Treatment with cardio-renal protective therapy was low, providing great potential for improvement.

BACKGROUND:Optimizing health-related quality of life (HRQoL) is a goal of preventive and therapeutic cardiovascular care worldwide, yet sex disparities in HRQoL remain insufficiently explored at a population level. The objective of this study was to examine sex differences in HRQoL in relation to secondary prevention in patients with CHD across all six World Health Organization regions. METHODS:Cross-sectional analysis of the INTERASPIRE study of adults hospitalized in the preceding six to 24 months with CHD who underwent standardized interview and examination across 14 countries. Endpoints were HRQoL (EQ-5D-5L; HeartQoL), and an INTERASPIRE-Guideline Target Score (GTS); a 10-point assessment of achieving secondary prevention lifestyle, risk factor, and therapeutic targets. Analyses were adjusted for age and country-level clustering. RESULTS:A total of 4546 patients (21.1% women) were interviewed. Compared to men, women had lower HRQoL across all assessments (p < 0.001) e.g., mean HeartQoL global score 2.1 vs 2.6; EQ-5D-5L self-care 17.8% vs 9.2%, and usual activities 39.1% vs 22.4%. Positive correlations (p < 0.001) were identified between HRQoL and INTERASPIRE-GTS. Female sex was independently associated with poor HRQoL (p < 0.001), either expressed by EQ-5D-5L index score or the HeartQoL overall and subscale scores. CONCLUSIONS:Female sex was independently associated with poorer HRQoL in patients with CHD. Higher HRQoL was associated with ability to achieve secondary prevention guideline targets. Routine integration of HRQoL assessment into secondary prevention programs can inform individualized clinical care and assist in reducing sex-based disparities in cardiovascular outcomes.

Observational studies and intervention trials provide the evidence base for developing strategies for primary and secondary prevention of cardiovascular disease (CVD). The Joint European Society of Cardiology recommendations on prevention of coronary heart disease published in 1994 was the first European guideline to summarize this evidence and propose prevention strategies for clinical practice with regular updates since. The implementation of these recommendations, and subsequent guidelines, was evaluated from 1996 onwards through the EUROASPIRE programme of surveys, which have evolved over a 30-year period, involving thousands of coronary and high-risk patients from hundreds of medical centres across 30 countries. This cycle of surveys over six iterations is described in this historical review, informing the need for quality improvements in real-life practice, both to prevent the development of atherosclerotic disease in high-risk individuals (primary prevention) and in those with established CVD (secondary prevention).

AIMS:Hypertension is a highly common cardiovascular risk factor, and a large proportion of patients with coronary heart disease (CHD) have uncontrolled hypertension. We report on the distribution and determinants of hypertension awareness, treatment, and control in CHD hypertensive patients. METHODS:The EUROASPIRE V survey included 8261 CHD patients from 27 countries. Awareness was defined as patients reporting being told by a health professional to have raised blood pressure (BP), being aware of their BP target and latest measurement. Patients using antihypertensive medication to lower BP were considered treated. Controlled hypertension was defined as BP <140/90mmHg (<140/85mmHg in patients with diabetes). Factors associated with hypertension awareness, treatment and control were identified with logistic regression. RESULTS:A total of 6496 EUROASPIRE V patients were considered hypertensive, from which 60.4% were aware, 91.7% were on treatment, and 46.8% were controlled. Number of antihypertensive drugs and adherence were independently associated with awareness (OR 1.23, 95%CI 1.16-1.31, and 2.18, 1.74-2.74 respectively) and control (1.11, 1.05-1.17 and 1.93, 1.57-2.37 respectively). Secondary (1.32, 1.03-1.68) and tertiary (1.70, 1.32-2.17) education and undertaking lifestyle changes (1.60, 1.37-1.87) were associated with awareness. Controlled patients were more often aware (1.43, 1.23-1.65) and had a healthier risk factor profile (BMI >25kg/m2 0.73, 0.61-0.87, diabetes 0.67, 0.59-0.76, LDL ≥1.8mmol/L 0.75, 0.65-0.86) than uncontrolled patients. CONCLUSION:Hypertension control remains poor in hypertensive CHD patients, despite high treatment and reasonable awareness levels. Communication with CHD hypertensive patients, especially those from vulnerable groups, needs to improve to facilitate change of health behaviours.

Dysglycaemia, defined as type 2 diabetes mellitus (T2DM) or impaired glucose tolerance (IGT), increases the cardiovascular risk and prognosis. INTERASPIRE performed in 14 countries across 6 WHO regions evaluated guideline adherence and management of patients with coronary artery disease (CAD) and dysglycaemia. A total of 4,548 CAD patients (18–80 years) were interviewed 6 months–2 years after hospital admission. All without diabetes were eligible for an oral glucose test (OGTT). Overall, 1990 (44

BACKGROUND AND OBJECTIVES:Chronic kidney disease (CKD) is commonly asymptomatic but associated with an increased risk of recurrent cardiovascular disease (CVD) events in people with coronary heart disease (CHD). The objective of this cohort study was to investigate the prevalence of CKD in individuals with established CHD, its determinants and short-term prognosis. METHODS:A total of 10349 patients with CHD (men 75.6%; average (SD) age 63.8 (9.6) years) were investigated with eGFR and urinary albumin/creatinine ratio (UACR). Follow-up data (median 1.6 years; IQR 1.2-2.0) for fatal and non-fatal cardiovascular CVD events were available in 9872 (95.4%) patients with time to the first CV-death, non-fatal myocardial infarction, stroke, hospitalization for heart failure, by-pass surgery or percutaneous coronary intervention as the primary endpoint. CKD was defined according to KDIGO as mild, moderate, high or very high (UACR 0-29 mg/g or 30-299 mg/g or ≥ 300 mg/g, respectively) and/or eGFR <60 ml/min/1.73 m2). RESULTS:Based on a combination of eGFR and UACR 27.3% of the patients had CKD, 18.2% at low or moderate and 9.1% at high or very high risk. Without an UACR 48.9% of these patients would not have been diagnosed. The risk, higher among women than men, correlated with age, history of diabetes, high waist-to-height ratio, low physical activity and hyperglycaemia. The primary endpoint was reached in 9.9% of the low-risk CKD patients, 15.0% of the moderate-risk and 22.2% of the high-risk patients. The risk remained significantly increased in the moderate and high-risk CKD stages after adjustment for CV risk factors (moderate risk: HR 1.39; 95%CI 1.19-1.63; p<0.0001; high-risk 1.75; 1.44-2.12; p<0001). CONCLUSION:CKD is common among people with CHD and constitutes an independent risk factor for recurrent CVD events. Many CKD cases would be missed without universal UACR screening. Accordingly, it is important to actively screen for the presence of CKD in CHD patients using both eGFR and UACR as there are several kidney protective therapeutic drugs available.

Background and Aims INTERASPIRE is an international study of coronary heart disease (CHD) patients, designed to measure if guideline standards for secondary prevention and cardiac rehabilitation are being achieved in a timely manner. Methods Between 2020 and 2023, adults hospitalized in the preceding 6-24 months with incident or recurrent CHD were sampled in 14 countries from all 6 World Health Organization regions and invited for a standardized interview and examination. Direct age and sex standardization was used for country-level prevalence estimation. Results Overall, 4548 (21.1% female) CHD patients were interviewed a median of 1.05 (interquartile range .76-1.45) years after index hospitalization. Among all participants, 24.6% were obese (40.7% centrally). Only 38.6% achieved a blood pressure (BP) < 130/80 mmHg and 16.6% a LDL cholesterol (LDL-C) of <1.4 mmol/L. Of those smoking at hospitalization, 48% persisted at interview. Of those with known diabetes, 55.2% achieved glycated haemoglobin (HbA1c) of <7.0%. A further 9.8% had undetected diabetes and 26.9% impaired glucose tolerance. Females were less likely to achieve the targets: BP (females 36.8%, males 38.9%), LDL-C (females 12.0%, males 17.9%), and HbA1c in diabetes (females 47.7%, males 57.5%). Overall, just 9.0% (inter-country range 3.8%-20.0%) reported attending cardiac rehabilitation and 1.0% (inter-country range .0%-2.4%) achieved the study definition of optimal guideline adherence. Conclusions INTERASPIRE demonstrates inadequate and heterogeneous international implementation of guideline standards for secondary prevention in the first year after CHD hospitalization, with geographic and sex disparity. Investment aimed at reducing between-country and between-individual variability in secondary prevention will promote equity in global efforts to reduce the burden of CHD.

This survey of secondary prevention of CVD was conducted through National Societies of Cardiology across all WHO regions and included Kenya, Nigeria, Tanzania, Argentina, Colombia, Egypt, UAE, Poland, Portugal, Indonesia, China, Malaysia, Philippines and Singapore. The overall aim of INTERASPIRE was to assess the clinical implementation of risk reduction initiatives to reduce cardiovascular risk in line with lifestyle, risk factor and therapeutic targets defined in international and national guidelines on CVD prevention. A consecutive sample of patients (> 18 and < 80 years) admitted to public hospitals in selected regions within each participating country with an acute ST elevation myocardial infarction (MI), Non-ST elevation MI, acute myocardial ischaemia or for elective revascularisation was identified retrospectively from medical record systems. Patients were invited to attend a clinical visit with trained research assistants at least 6 months but not more than 2 years after their event. The assessment included self-reported smoking status validated with an expired breath carbon monoxide measurement, self-reported participation in physical activity using the Godin validated questionnaire and standardised measurements of height, weight, blood pressure, blood lipids and blood glucose including an oral glucose tolerance test. 4548 (21.1% women) patients attended the clinical visit. 12.6% were smoking with wide variation across countries (1.9 – 27.3%). 48% of those who were smoking at the time of hospital admission had continued to smoke. 66.5% reported being sedentary with wide variation across countries (51.3 – 90.5%). 24% were obese and 40% centrally obese with a large difference between men (32.3%) and women (69.4%). 38% achieved a blood pressure target of < 130/80 mmHg, 19.2% achieved an LDL-C target of < 1.4 mmol/l and in patients with self-reported diabetes 56% achieved a target HbA1c of < 53 mmol/mol (7%). In those who did not report having diabetes, a further 9.8% had undetected diabetes and 26.9% impaired glucose tolerance. 48% were prescribed all four classes of cardioprotective drugs (antiplatelets, beta blockers, ACE/ARB, lipid lowering agents) with wide variation between countries (25% - 75%) and 88.3% were prescribed both antiplatelets and lipid lowering agents. Only 1219 (26.8%) were advised to attend cardiac rehabilitation with wide variation (4.5% to 58.9%) between countries. Overall only 9.0% (men 9.1%, women 9.1%) of all patients attended cardiac rehabilitation. Figure 1 shows the distribution of the INTERASPIRE Guideline Target Score. There is substantial room for improvement in secondary prevention in patients with coronary disease globally. It is of concern that only 9% of patients received cardiac rehabilitation despite it being a Class 1 recommendation in all prevention guidelines with wide variation in advice and uptake between countries.Figure 1

BACKGROUND:Glucose perturbations can be detected by fasting plasma glucose (FPG), HbA1c, and the oral glucose tolerance test (OGTT). The highest yield is provided by OGTT. HbA1c is considered more practical. We compare the diagnostic and predictive performance of these glycaemic indicators based on combined data from the EUROASPIRE IV (EAIV) and V (EAV) studies. METHODS:This cohort study was conducted in 79 centres in 24 European countries (EAIV) and 131 centres in 27 European countries (EAV). Eligible patients were aged 18-80 years, did not have diabetes, and were diagnosed with coronary artery disease 6-36 months (EAIV) or 6-24 months (EAV) before the investigation. Patients were investigated with OGTT (FPG and 2 h post-load glucose [2-hPG]) and HbA1c. Follow-up of subsequent cardiovascular events was done by means of a questionnaire at least 1 year after the baseline investigation. Analyses were done in patients with both OGTT and HbA1c data available. Outcome analysis in these patients was restricted to those with valid follow-up data available. FINDINGS:16 259 patients were interviewed in EAIV (2012-13) and EAV (2016-17). 8364 patients had both OGTT and HbA1C data and were included in the analysis population (3932 in EAIV and 4432 in EAV). Information on cardiovascular events was available in 7892 patients. Follow-up was for a median 1·6 years (IQR 1·2-2·0). The average patient age was 63·3 years (SD 9·8), and 6346 (75·9%) of 8364 patients were men. At baseline, 1856 (22·5%) of 8263 patients were determined to have newly detected type 2 diabetes using OGTT alone, compared with 346 (4·2%) using HbA1c alone. New dysglycaemia, defined as newly detected type 2 diabetes or impaired glucose tolerance (IGT), was present in 3896 (47·1%) of the patients according to 2hPG. 2hPG 9 mmol/L or greater (162 mg/dL, adjusted hazard ratio [aHR] 1·58; 95% CI 1·27-1·95, p<0·0001), and HbA1c 5·9% or greater (41 mmol/mol, aHR 1·48, 1·19-1·84; p=0·0010) were the strongest predictors of cardiovascular events, while FPG did not predict. A multivariable model showed that the effect of HbA1c on cardiovascular events was mainly explained by 2hPG (aHR for 1 unit increase in HbA1c 1·13, 0·98-1·30; p=0·11; and aHR for 1 unit increase in Ln[2hPG] 1·37, 1·08-1·74; p=0·0042). INTERPRETATION:2hPG appears better than HbA1c in detecting dysglycaemia and predicting its impact on future cardiovascular events in patients with coronary artery disease and should be recommended as the primary screening tool. FUNDING:Swedish Heart-Lung Foundation, Region Stockholm (ALF), the Erling Persson Foundation, the Baltic Child Foundation.

13 February 2023 and is remembered as one of the European giants in cardiovascular disease (CVD

Introduction Cardiovascular disease is still a leading cause of death in Poland and across Europe. The aim of this study was to assess the attainment of the main treatment goals for secondary cardiovascular prevention in coronary patients with or without diabetes mellitus (DM) in Poland. Material and methods The study group included 1026 patients (65.5 ±9 y.o.; males: 72%) included at least 6 months after the index hospitalisation for myocardial infarction, unstable angina, elective percutaneous coronary intervention or coronary artery bypass surgery. The target and treatment goals were defined according to the 2016 European Society of Cardiology guidelines on cardiovascular prevention. Results Patients with DM (n = 332; 32%) were slightly older compared to non-diabetic (n = 694) individuals (67.2 ±7 vs. 64.6 ±9 years old; p < 0.0001). The DM goal was achieved in 196 patients (60%). The rate of primary (LDL: 51% vs. 35%; p < 0.0001) and secondary (non-HDL: 56% vs. 48%; p < 0.02) goal attainment was higher in DM(+) compared to DM(–) patients. The rate of target blood pressure was lower in DM(+) than in normoglycemic patients (52% vs. 61% at < 140/90 mm Hg, p < 0.01. As expected, goal achievement of normal weight (9.5% vs. 19%; p < 0.0001) and waist circumference (7% vs. 15%; p < 0.001) was lower in diabetic patients and the rate of regular physical activity was similar (DM+ 12% vs. DM– 14%; p = ns). Finally, there was no difference in active smokers (DM+ 23% vs. DM– 22%; p = ns). Conclusions Great majority of Polish patients in secondary prevention do not achieve treatment goals. Although lipid goals attainment is better in DM and the rate of smokers is similar, the management of all risk factors needs to be improved.

AimsThe aim of this study was to provide an up-to-date overview of gender differences or similarities in risk factor control and medical management in the Belgian CHD population.MethodsAll analyses are based on the ESC EORP EUROASPIRE IV and EUROASPIRE V (European Survey Of Cardiovascular Disease Prevention And Diabetes) surveys. Patients between 18 and 80 years old, hospitalised for a first or recurrent coronary event, were included in the survey.ResultsData were available for 10,519 patients, of which 23.9% were women. Women had a worse risk factor profile compared to men. Women were more physical inactive (OR = 1.31, 95% CI = 1.19-1.44), had a higher prevalence of obesity (OR = 1.37, 95% CI = 1.25-1.50) and had a worse LDL-C control (OR = 1.52, 95% CI = 1.36-1.70). Moreover, women were less likely to use ACE-I/ARBs (OR = 0.84, 95% CI = 0.76-0.94) and statins (OR = 0.79, 95% CI = 0.70-0.90). In addition, little gender differences were found in patients' risk factor awareness, except on cholesterol awareness. Women were more aware about their total cholesterol levels (OR = 1.37, 95% CI = 1.21-1.56).ConclusionDespite little to no gender differences in the management of CHD patients, women still have a worse risk factor profile, both in Belgian and in other European high-income countries.

The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal Open or of the European Society of Cardiology. * Corresponding author. Tel: +32 92826970, Email: guy.debacker@ugent.be © The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com This editorial refers to ‘Achievements of primary prevention targets in individuals with high risk of cardiovascular disease: an 8-year follow-up of the Tromsø study’, by A. N. Hagen et al. https://doi.org/10.1093/ehjopen/oeac061.

Aims: An oral glucose tolerance test (OGTT) combining fasting (FPG) and 2-hour plasma glucose (2hPG) is the most sensitive method for detecting type 2 diabetes (T2DM). Since it is considered time-consuming, we aim at validating a previously proposed screening algorithm based on a 1-hour plasma glucose (1hPG) with a 12 mmol/L threshold. Methods: Nine-hundred-eighteen patients with coronary artery disease (CAD) without known T2DM from the EUROASPIRE V cross-sectional survey underwent an OGTT. The reference for T2DM was 2hPG > 11.1 mmol/L. T2DM diagnosis by HbA1c > 6.5%(48 mmol/mol), FPG > 7.0 mmol/L, and 1hPG > 12 mmol/L were compared with the outcome of 2hPG. Results: Mean FPG, HbA1c and 2hPG were 6.1 mmol/L, 5.6%(38 mmol/mol) and 7.8 mmol/L respectively. Ninety-six patients (10%) were diagnosed with T2DM according to 2hPG. Using this definition, in the group with FPG < 6.5 mmol/L and 1hPG < 12 only 5 (1%) were misdiagnosed as false negatives. All patients with a FPG > 8.0 mmol/L and 1hPG > 15.0 mmol/L were identified as having T2DM. According to the algorithm, in 79% of patients T2DM could be excluded by combining FPG < 6.5 mmol/L and 1hPG < 12 mmol/L. Conclusions: T2DM Screening by means of an algorithm combining FPG and 1hPG limits the demand of a 2hOGTT in 79% of CAD patients without known T2DM. HbA1c did not add to the information derived from this algorithm. (c) 2021 Published by Elsevier B.V.

AIMSMost patients with established atherosclerotic cardiovascular disease (CVD) are at very high risk for developing recurrent events. Since this risk varies a lot between patients there is a need to identify those in whom an even more intensive secondary prevention strategy should be envisaged. Using data from the EUROASPIRE IV and V cohorts of coronary heart disease (CHD) patients from 27 European countries, we aimed at developing and internally and externally validating a risk model predicting recurrent CVD events in patients aged < 75 years.METHODS AND RESULTSProspective data were available for 12 484 patients after a median follow-up time of 1.7 years. The primary endpoint, a composite of fatal CVD or new hospitalizations for non-fatal myocardial infarction (MI), stroke, heart failure, coronary artery bypass graft, or percutaneous coronary intervention (PCI), occurred in 1424 patients. The model was developed based on data from 8000 randomly selected patients in whom the association between potential risk factors and the incidence of the primary endpoint was investigated. This model was then validated in the remaining 4484 patients. The final multivariate model revealed a higher risk for the primary endpoint with increasing age, a previous hospitalization for stroke, heart failure or PCI, a previous diagnosis of peripheral artery disease, self-reported diabetes and its glycaemic control, higher non-high-density lipoprotein cholesterol, reduced renal function, symptoms of depression and anxiety and living in a higher risk country. The model demonstrated excellent internal validity and proved very adequate in the validation cohort. Regarding external validity, the model demonstrated good discriminative ability in 20 148 MI patients participating in the SWEDEHEART register. Finally, we developed a risk calculator to estimate risks at 1 and 2 years for patients with stable CHD.CONCLUSIONIn patients with CHD, fatal and non-fatal rates of recurrent CVD events are high. However, there are still opportunities to optimize their management in order to prevent further disease or death. The EUROASPIRE Risk Calculator may be of help to reach this goal.