Purpose Secondary prevention of stroke requires effective cardiovascular risk factor (RF) management, including blood pressure control, lipid lowering treatment and antithrombotic therapy to reduce the risk of recurrent stroke. Optimal management of risk factors is challenging in older, frailer people, who also have worse outcomes after a stroke. There is limited evidence evaluating secondary prevention quality and outcomes in frail populations. To understand the trends (and factors associated with inequity) in the provision of RF management we developed the `Evaluation of Population Secondary Prevention Quality and Outcomes Post-Stroke (ESP-QOPS) in Wales' e-cohort. The aims of this project include describing (i) the provision of post-stroke evidence-based risk factor management (ii) trends in frailty and outcomes, and (iii) evaluating the impact of suboptimal risk factor provision on adverse outcomes stratified by frailty status. Participants We identified 71,696 patients with a first recorded stroke diagnosis in primary or secondary care between 2010-2023 in Wales. Findings to Date The incidence of stroke gradually increased from 4,968 to 5,391 patients per year between 2010-2023, with 70% of diagnoses made in the secondary care setting. Of diagnoses made in primary care, less than 20% were subsequently admitted to secondary care.

BACKGROUND:Pregnancy-related complications are linked to increased cardiovascular disease risk, but comprehensive evaluations of diverse complications, particularly multiple or recurrent events, are limited. METHODS:A national retrospective cohort study was conducted using the Secure Anonymised Information Linkage (SAIL) Databank in Wales. Exposures were hypertensive disorders of pregnancy, gestational diabetes, placental abruption, stillbirth, small for gestational age, fetal growth restriction, and preterm birth. Multiple complications were defined as >1 complication in the first pregnancy, and recurrent complications as the same complication in both the first and second pregnancies. Outcomes were incident ischemic heart disease, stroke, heart failure, and atrial fibrillation. Cox regression estimated hazard ratios (HRs). RESULTS:A total of 298 515 women (mean age 27.2 years; SD 6.1) were included. Multiple pregnancy-related complications were associated with increased risk of ischemic heart disease (hazard ratio HR, 2.88 [95% CI, 2.27-3.67]), stroke (HR, 2.03 [95% CI, 1.55-2.65]), heart failure (HR, 3.18 [95% CI, 2.34-4.32]), and atrial fibrillation (HR, 1.80 [95% CI, 1.20-2.72]) compared with no complications. A dose-response relationship was observed, with progressively higher cardiovascular disease risk for multiple compared with single complications and elevated risk for both groups relative to women without complications. Recurrent pregnancy-related complications increased the risk of ischemic heart disease (HR, 1.93 [95% CI, 1.26-2.95]), stroke (HR, 1.89 [95% CI, 1.25-2.85]), heart failure (HR, 3.61 [95% CI, 2.32-5.60]), and atrial fibrillation (HR, 2.45 [95% CI, 1.38-4.37]) compared with no complication. CONCLUSIONS:Women experiencing pregnancy-related complications encounter higher risks of cardiovascular disease, especially with multiple or recurrent complications. Comprehensive cardiovascular risks assessment and targeted prevention should be prioritized for this group.

Myocardial perfusion imaging (MPI) is frequently used to improve cardiac risk prediction in patients undergoing non-cardiac surgery. However, the data supporting this practice is derived from single center studies and predates current therapy for coronary artery disease (CAD). We evaluated the association between pre-operative testing indication and outcomes as well as predictors of death or myocardial infarction (MI) in these patients. We include patients from the international, multicenter REFINE-SPECT registry (13 sites). Based on referral indication, patients were classified as pre-operative testing indications and non-pre-operative testing. We evaluated the associations between pre-operative testing and incidence of death or MI. We then evaluated associations with death or MI in patients referred for pre-operative testing compared to other patients. In total, 32,711 patients were included with pre-operative testing as the indication in 2,173(6.6

Objectives Carotid intima-media thickness (CIMT) is reflective of arterial aging and injury. However, there are inconsistencies in the reported associations between CIMT measurements and CVD risk, specifically mean versus maximum CIMT, the role of carotid plaque location and quantity. This study explores the associations of these measures in older adults. Design A longitudinal analysis of data from the British Regional Heart Study, a prospective cohort study Participants 1315 men aged 71-92 years, without baseline coronary heart disease (CHD) or stroke Methods: Between 2010-2012, participants underwent follow-up, comprising of questionnaires, physical examination, and blood tests. CIMT and carotid plaque characteristics (location and quantity) were assessed using ultrasound. Cox proportional hazards models estimated multivariate-adjusted hazard ratios (HR) for incident CHD and stroke (fatal/non-fatal), based on CIMT and plaque features. Results: Over a median follow-up of 10.2 years, 108 incident CHD cases and 110 incident stroke cases (fatal/non-fatal) occurred. After adjusting for confounders (age, social class, smoking, exercise, alcohol intake, BMI, medications, comorbidities, blood pressure, cholesterol, CRP and NT-pro BNP), no significant associations were found between mean or maximum CIMT and CHD or stroke events (fatal/non-fatal). However, both mean and maximum CIMT were significantly associated with fatal CHD events (HR 1.38, CI 1.07-1.76 and HR 1.30, CI 1.02-1.61, respectively per standard deviation increase in CIMT). No significant association was observed with fatal stroke events. Stroke risk increased with increasing number of carotid plaques (HR 1.29, CI 1.04-1.61) which was seen for both fatal and non-fatal strokes. No association was seen with CHD. When examined by plaque location, plaques located in the common carotid artery (CCA) was associated with incident stroke events (HR 1.73, CI 1.06-2.83) and to a lesser extent with CHD (HR 1.48, CI 0.9-2.43). No associations were seen for other sites. Conclusion: In older men, mean and maximum CIMT are more associated with fatal CHD events than with non-fatal CHD. No significant association was found between CIMT (mean or maximum) and incident stroke events. However, the presence of carotid plaques, particularly in the CCA and in greater quantities, is strongly associated with an increased risk of stroke (fatal/non-fatal). These findings suggest that CVD risk varies according to measures of CIMT in older men.

Aims:In patients with diabetes mellitus (DM) and atherosclerotic cardiovascular disease (ASCVD), or without ASCVD (primary prevention), the prescribing of lipid lowering therapy (LLT) is an established treatment strategy endorsed by clinical guidelines. This study aimed to document (i) trends in presentation of DM, (ii) treatment, monitoring and achievement of target low-density lipoprotein cholesterol (LDL-C) in DM with ASCVD, and (iii) ASCVD risk assessment and lipid treatment according to risk in the DM primary prevention setting. Methods and results:A retrospective observational population study including 282 581 DM patients using linked health-care data (2010-23) in Wales. The prevalence of DM (documented DM diagnosis in record prior to the beginning of the year) increased from 133 439 in 2010 to 183 948 in 2023 (6504 to 8200 per 100 000), along with increasing incidence (new diagnosis of DM documented in record during specific year) with 11 074 cases in 2010 (540 per 100 000 per year), increasing to 14 539 in 2023 (648 per 100 000 per year). The proportion of prevalent patients with established ASCVD prescribed LLT decreased from 87.5% to 81.8% (2010-23), testing of LDL-C decreased from 70.3% to 67.1%, and of those with documented lipids 41.0% achieved an LDL-C <1.8 mmol/L in 2010 increasing to 52.2% in 2023. Amongst DM without ASCVD, the proportion prescribed LLT decreased from 78.9% to 54.9% in those with chronic kidney disease (CKD) and from 70.7% to 55.6% in those without CKD. Considering DM without ASCVD or CKD (LLT is recommended according to 10-year CVD risk), only 44.2% of incident DM had a documented QRISK score in 2022 and of those with a 10-year risk >20%, only half were prescribed LLT. Conclusion:Increasing incidence and prevalence of DM, together with decreasing quality of risk factor management has the potential to lead to poorer health outcomes in the population if not addressed more effectively.

Background: Atherosclerotic cardiovascular disease (ASCVD) most often manifests initially with a myocardial infarction or stroke. While the aetiology of atherosclerosis and benefits of risk factor (lipids and blood pressure) management are well established, less is known about the effectiveness of ASCVD risk assessment and management in the period leading up to such events. Aims: To identify patients with a major coronary or cerebrovascular event at first presentation of ASCVD between 2010-23 and assess identification and management of ASCVD risk in the year preceding the event. Methods: We conducted a retrospective, population-level,observational study using linked anonymised health record data amongst 102,148 patients with a fatal or non-fatal major coronary or cerebrovascular event at first ASCVD diagnosisin Wales (UK). Trends in the documentation of QRISK 10-year risk score, management of LDL-C and blood pressure(BP), and prescription of lipid lowering therapy (LLT) were identified in the year preceding presentation. Results: Documentation of LDL-C in the year prior to presentation increased from 27.8% to 38.5% between 2010-23, of which the proportion with a level of <1.8 mmol/L increased from 4.5% to 9.5% (Figure 1A). Prescription of LLT increased from 26.0% to 33.8% between 2010-23, with an increase in the prescribing of high-intensity statin from 2.0% to 6.7% (Figure 1B). Documentation of BP decreased from 55.2% to 49.8% between 2010-23, and achievement of systolic and diastolic BP <140&90 mmHg increased, thoughonly from 26.5% to 27.4% (Figure 1C). Documentation of QRISK score within 5-years prior to presentation increased from 16.1% to 27.7% between 2014-23, of which 28.1% scored >20% in 2023 (Figure 1D). Among patients with a recorded QRISK of >20%, only 19.1% were prescribed LLTin 2014, increasing to 27.5% in 2023 (Figure 1E). Conclusions: Although management of lipids has improved over time in the primary prevention setting, the effectiveness of control of patient's risk factors remains suboptimal at a population level. The majority of patients suffering MI or stroke as their initial presentation of CVD do not have their BP or lipids tested (or controlled when tested) in the year preceding initial presentation with these acute vascular events.Improvements are required in identification of those at risk and management of modifiable risk factors to meet guideline-recommended standards of care at the population level.

Background: In patients with atherosclerotic cardiovascular disease (ASCVD), guidelines recommend a reduction in low-density lipoprotein cholesterol (LDL-C) to target levels with statin therapy as required. Where targets are not achieved, escalation to higher intensity statin +/- additional lipid-lowering therapy (LLT) is recommended. It is unknown to what extent adjustments in LLT are made after LLT initiation in routine practice, in relation to measured LDL-C levels. Aims: To document (i) testing and (ii) achievement of ESC guideline-recommended LDL-C levels (<1.8 mmol/L), in relation to (iii) prescribed LLT regimen during the first two years post-ASCVD diagnosis. Methods: A retrospective, population-level, observational study using linked anonymised population electronic health record (EHR) data amongst 178696 patients diagnosed with ASCVD between 2010-22, with at least one year of follow-up data. Patients were followed up for two years post-diagnosis, and censored at the point of death, migration, or loss of linked primary care data. Results: Within 90-days post-diagnosis only 36318 (20.3%) patients had LDL-C levels documented in their EHR, of which 7.3% were <1.8 mmol/L. Of those 23446 (13.1%) patients with LDL-C ≥1.8 mmol/L, 12.7% were receiving high-intensity statin therapy or combination LLT (HI), 40% had lower-intensity statin therapy or other LLT monotherapy (LI) and 47.3% were not treated (Figure 1). During the first-year post-diagnosis, only 4222 (2.4%) had LDL-C tested and 929 (22%) of these achieved target. Of those not achieving target, 15.9% were prescribed HI-LLT, 43.4% LI-LLT, and 40.7% were not treated (Figure 1). Among patients with no test at one-year, 48.1% were prescribed LLT and 51.9% were not treated. Of those not treated, 78.7% received no test or treatment by two-years post-diagnosis. By two-years post-ASCVD diagnosis, 12.5%, 27.2%, and 54.5% were prescribed HI, LI, and no LLT respectively. Figure 1 illustrates that most patients were not tested following 90-days post-diagnosis and remained on the initial LLT regime over the subsequent two-years. Conclusions: Management of lipids was below guideline-recommended standards in the early years following ASCVD diagnosis in the population, with low levels of testing and escalation in lipid treatment regimen uncommon, even when indicated by documented LDL-C levels. A more rigorous system-wide approach to LLT is required to maximise the potential benefits among these very high-risk patients.

Background and Aims:Revascularization in stable coronary artery disease often relies on ischemia severity, but we introduce an AI-driven approach that uses clinical and imaging data to estimate individualized treatment effects and guide personalized decisions. Methods:Using a large, international registry from 13 centers, we developed an AI model to estimate individual treatment effects by simulating outcomes under alternative therapeutic strategies. The model was trained on an internal cohort constructed using 1:1 propensity score matching to emulate randomized controlled trials (RCTs), creating balanced patient pairs in which only the treatment strategy-early revascularization (defined as any procedure within 90 days of MPI) versus medical therapy-differed. This design allowed the model to estimate individualized treatment effects, forming the basis for counterfactual reasoning at the patient level. We then derived the AI-REVASC score, which quantifies the potential benefit, for each patient, of early revascularization. The score was validated in the held-out testing cohort using Cox regression. Results:Of 45,252 patients, 19,935 (44.1%) were female, median age 65 (IQR: 57-73). During a median follow-up of 3.6 years (IQR: 2.7-4.9), 4,323 (9.6%) experienced MI or death. The AI model identified a group (n=1,335, 5.9%) that benefits from early revascularization with a propensity-adjusted hazard ratio of 0.50 (95% CI: 0.25-1.00). Patients identified for early revascularization had higher prevalence of hypertension, diabetes, dyslipidemia, and lower LVEF. Conclusions:This study pioneers a scalable, data-driven approach that emulates randomized trials using retrospective data. The AI-REVASC score enables precision revascularization decisions where guidelines and RCTs fall short.

BACKGROUND:Coronary artery disease (CAD) and peripheral artery disease (PAD) are often regarded as analogous risk factors for major adverse cardiovascular events (MACE), given their shared pathophysiology. We aimed to investigate whether the elevated MACE risk in PAD is driven by myocardial perfusion abnormalities or through other PAD-specific mediators. METHODS:We analyzed 45,252 patients from an international, multicentre registry who underwent SPECT myocardial perfusion imaging, excluding those with early coronary revascularization (< 90 days). Myocardial perfusion abnormalities were quantified using total perfusion deficit (TPD). MACE was defined as all-cause mortality, unstable angina admission, myocardial infarction, or late coronary revascularization. PAD was defined using questionnaires or review of electronic medical records. Propensity-score matching was used to select balanced groups of patients with and without PAD. RESULTS:During a median follow-up of 3.6 years (interquartile range [IQR]: 2.6-4.8 years), 5932 patients (13.7%) experienced at least 1 MACE. Compared with patients with neither disease, isolated history of CAD (adjusted hazard ratio [aHR], 1.92; 95% confidence interval [CI], 1.80-2.05) conferred a similar MACE risk as concomitant history of CAD and PAD (aHR, 1.57; 95% CI, 1.44-1.71) and greater risk than isolated history of PAD (aHR, 1.20; 95% CI, 1.09-1.32; P < 0.001). After propensity-score matching, history of PAD alone was not independently associated with increased MACE risk (P = 0.064). CONCLUSIONS:Although patients with PAD often have concomitant CAD and greater myocardial perfusion abnormalities, PAD itself was not linked to higher risk of MACE after adjusting for these factors. These findings highlight the importance of assessing myocardial ischemic burden in PAD for risk stratification and prompt initiation of disease-modifying therapies.

Abstract Background European Society of Cardiology 2021 guidelines recommend 4 pillars of treatment to reduce mortality for those with heart failure (HF) and reduced ejection fraction (HFrEF): pillar 1) angiotensin converting enzyme inhibitor (ACE-I)/angiotensin receptor blocker (ARB)/angiotensin receptor-neprilysin inhibitor (ARNI), pillar 2) beta-blocker (BB), pillar 3) mineralocorticoid receptor antagonist (MRA), pillar 4) sodium-glucose co-transporter 2 inhibitor (SGLT2i). When there is heart failure with preserved ejection fraction (HFpEF), guidelines recommend diuretics to alleviate congestion and treatment of risk factors such as hypertension and diabetes. Prior to 2021, United Kingdom guidelines did not include SGLT2i. Purpose To examine how HF treatment is recorded in routinely-collected electronic health record (EHR) data for older people in Wales, and to explore how that has changed since 2015. Methods We conducted a retrospective, population-level, observational study using linked anonymised EHR data in Wales (2015-22). 737,230 individuals were aged 65y+ in the study period (21.5% of population in 2022). Of these, 65,010 had a code for heart failure in their primary or secondary care records. We excluded 13,990 individuals with fewer than 12 months data pre- or post-diagnosis. We looked forward, from HF diagnosis, for codes associated with specific medications. Results The final cohort comprised 51,020 individuals aged 65y and over with a diagnosis of heart failure between 2015-2022. Incidence and prevalence of heart failure increased across the study period (1.4-1.5% and 8.5-9.1% respectively). Preceding cardiovascular diagnoses included hypertension (69.5%), atrial fibrillation (36.7%), myocardial infarction (30.5%), coronary artery disease (25.7%), and valve disease (17.7%). Diabetes (41.7%), chronic kidney disease (30.9%) and cancer (26.4%) were the most common comorbidities. The subtype of HF (HFrEF or HFpEF) was only evident in 5,850. Treatments recorded most often were loop diuretics, ACE-I, and BB (Table 1). SGLT2i codes increased in 2020/2021(Figure 1). At 10-12 months post diagnosis, the proportion with simultaneous pillar combinations was; 27.4% 1 + 2, 12.5% 1, 2 + 3, and only 2% 1, 2, 3 + 4. Conclusions In Wales, there is a need to improve the coding of HF subtype in primary care records. We suggest interpreting data with the assumption that approximately half of the cohort are likely to have HFrEF. While the cohort proportion on ACE-I or beta-blockers may be appropriate, the proportion with more than 1 simultaneous pillar of treatment recorded appears low. The use of SGLT2i in codes is increasing. These results are important in evaluating health service delivery and in establishing baseline data from which to monitor improvements.

BACKGROUND:The Atrial fibrillation Better Care (ABC) pathway is the gold-standard approach to atrial fibrillation (AF) management, but the effect of implementation on health outcomes in care home residents is unknown. OBJECTIVE:To examine associations between ABC pathway adherence and stroke, transient ischaemic attack, cardiovascular hospitalisation, major bleeding, mortality and a composite of all these outcomes in care home residents. METHODS:A retrospective cohort study of older care home residents (≥65 years) in Wales with AF was conducted between 1 January 2003 and 31 December 2018 using the Secure Anonymised Information Linkage Databank. Adherence to the ABC pathway was assessed at care home entry using pre-specified definitions. Cox proportional hazard and competing risk models were used to estimate the risk of health outcomes according to ABC adherence. RESULTS:From 14,493 residents (median [interquartile range] age 87.0 [82.6-91.2] years, 35.2% male) with AF, 5,531 (38.2%) were ABC pathway adherent. Pathway adherence was not significantly associated with risk of the composite outcome (adjusted hazard ratio, 95% confidence interval [CI]: 1.01 [0.97-1.05]). There was a significant independent association observed between ABC pathway adherence and a reduced risk of myocardial infarction (0.70 [0.50-0.98]), but a higher risk of haemorrhagic stroke (1.59 [1.06-2.39]). ABC pathway adherence was not significantly associated with any other individual health outcomes examined. CONCLUSION:An ABC adherent approach in care home residents was not consistently associated with improved health outcomes. Findings should be interpreted with caution owing to difficulties in defining pathway adherence using routinely collected data and an individualised approach is recommended.

Abstract Background Heart failure (HF) is associated with high healthcare resource use and mortality. Most of the evidence focuses on hospital admission data. The impact on primary care interactions and outpatient attendance is less well described, but this information is important in understanding resource utilisation, patient pathways, and in planning services. Purpose To examine how a diagnosis of HF impacts healthcare resource use and outcomes for older people in Wales. Methods We conducted a retrospective, population-level, observational study using linked anonymised electronic health record (EHR) data in Wales (2015-22). 737,230 individuals were aged 65y+ in the study period in primary and secondary care data. Of these, 65,010 had a code for HF in their primary or secondary care records. To evaluate changes in resource use, we excluded 13,990 individuals with fewer than 12 months health data pre- and post-diagnosis. We summarised general practice (GP) interactions, emergency department (ED) attendance, outpatient (OP) attendance, inpatient (IP) episodes and days, time between HF diagnosis and death, and place of death. Results The final cohort comprised 51,020 individuals 65y and over with a diagnosis of HF between 2015-2022. Incidence and prevalence of HF increased across the study period (1.4-1.5% and 8.5-9.1% respectively). Figure 1 shows the percentage change in healthcare resource use for the cohort when HF was diagnosed (12 months pre-and post-diagnosis comparison). Table 1 shows the average number of healthcare utilisation events per person. After a diagnosis of HF, there are fewer ED attendances (-28.2%) and IP admissions (-9.3%) but more OP appointments (31%) and GP interactions (20.3%). When admissions occur, hospital stays tend to be longer (55.4%). Median time (IQR) from HF diagnosis to death from any cause was 247(34-840) days, and with HF listed as a cause 186(25-780) days. In this cohort, the place of death was recorded as NHS establishment (20,379, 67.8%), community (5,450, 18.1%), non-NHS establishment (3,789,12.6%) and unknown (450, 1.5%). Conclusions In Wales, a diagnosis of HF in those 65y+ increases primary care interactions and OP attendances. The change in volume of primary care interactions is considerable (increase from 1,047,920 to 1,315,080). Longer hospital stays may suggest difficulty in managing patients or discharging back to community settings. Majority of those with HF die in NHS establishments. It is unclear whether this reflects deficits in end-of-life care. These results are important in planning effective health service delivery and in establishing baseline data from which to monitor quality improvements.

Aims European clinical guidelines recommend that patients with atherosclerotic cardiovascular disease (ASCVD), including ischaemic heart disease (IHD), stroke, and peripheral arterial disease (PAD), are prescribed lipid lowering treatment (LLT) and treated to target low-density lipoprotein cholesterol (LDL-C) levels. This study aimed to document trends in ASCVD, including treatment, monitoring, and achievement of target LDL-C. Methods and results A retrospective observational population study was performed using linked healthcare data (2010-22). Over the study period, the number of patients with ASCVD increased from 181 153 to 207 747 (8882 to 9398 per 100 000). The proportion of patients prescribed LLT decreased from 75.3% in 2010 to 67.1% in 2022; high-intensity statin therapy increased from 9.4 to 25.2%, while non-high-intensity statin therapy decreased from 59.6 to 38.2%. The prescription of high-intensity statin therapy was consistently higher amongst patients with IHD (10.9% in 2010 increasing to 28.0% in 2022) than in patients with stroke (4.7-21.6%) or PAD (3.9-10.6%). The proportion of cases with documented LDL-C decreased from 58.0% in 2010 to 49.3% in 2022. Of those with documented LDL-C in 2022, 44.0% achieved LDL-C < 1.8 mmol/L, including 45.2% of those with IHD, 42.0% of those with stroke, and only 32.8% of those with PAD. Methods and results A retrospective observational population study was performed using linked healthcare data (2010-22). Over the study period, the number of patients with ASCVD increased from 181 153 to 207 747 (8882 to 9398 per 100 000). The proportion of patients prescribed LLT decreased from 75.3% in 2010 to 67.1% in 2022; high-intensity statin therapy increased from 9.4 to 25.2%, while non-high-intensity statin therapy decreased from 59.6 to 38.2%. The prescription of high-intensity statin therapy was consistently higher amongst patients with IHD (10.9% in 2010 increasing to 28.0% in 2022) than in patients with stroke (4.7-21.6%) or PAD (3.9-10.6%). The proportion of cases with documented LDL-C decreased from 58.0% in 2010 to 49.3% in 2022. Of those with documented LDL-C in 2022, 44.0% achieved LDL-C < 1.8 mmol/L, including 45.2% of those with IHD, 42.0% of those with stroke, and only 32.8% of those with PAD. Conclusion Prescription of LLT, including high-intensity statin therapy, documentation of LDL-C, and achievement of target LDL-C levels was relatively low, especially in PAD patients. Although target achievement in 'tested patients' increased over time, the proportion of patients undergoing lipid testing declined. More rigorous lipid management requires prioritisation, especially for PAD and stroke patients. We analysed trends in the presentation of atherosclerotic cardiovascular disease and lipid management in a population between 2010 and 2022. The number of patients with atherosclerotic cardiovascular disease increased by 14%, but the proportion receiving lipid lowering therapy decreased.Patients with ischaemic heart disease were more effectively managed than patients with stroke.Patients with peripheral arterial disease were the least effectively managed. [GRAPHICS] .

Background: In patients with diabetes mellitus (DM), lipid-lowering therapy (LLT) with statins +/- adjuvant LLT are recognised treatment approaches. It is unknown what proportion of patients with DM are prescribed LLT, have documented low-density lipoprotein cholesterol (LDL-C) levels, or achieve guideline LDL-C targets. Aims: To document population trends in (i) the incidence and prevalence of DM, (ii) prescribing of LLT, and (iii) testing and achievement of LDL-C targets in patients with or without atherosclerotic cardiovascular disease (ASCVD). Methods: We conducted a retrospective, population-level, observational study using linked anonymised health record data amongst 269,735 diabetic patients in Wales (UK). Associations between patient characteristics and (i) statin prescription and (ii) achievement of LDL-C target of (<1.8 mmol/L) were evaluated. Results: The prevalence of DM increased from 6,519 to 8,128 per 100k, and incidence increased from 543 to 633 per 100k per year (2010-21). The proportion of patients prescribed any LLT decreased from 89.5% to 82.9% in those with ASCVD and from 53.2% to 37.8% without. An increasing and greater proportion of patients with ASCVD were prescribed high-intensity statin therapy (14.1% to 36.1%) over the study period, compared to those without (2.3% to 5.1%; Figure 1). The proportion of patients with documented LDL-C decreased (from 68.1% to 52.3% in those with ASCVD and 64.7% to 48.3% without) over the study period. A greater proportion of those with ASCVD achieved an LDL-C <1.8 mmol/L (43.1% to 45.4%) than those without (22.2% to 22.0%). In a multivariate logistic regression, presence of ASCVD and history of hypertension were associated with prescription of statin therapy (ORs = 4.01, 1.75, respectively; both p < 0.01). Male sex and presence of ASCVD were associated with achievement of LDL-C target (ORs = 1.25, 8.15; both p < 0.01). Conclusions: The incidence and prevalence of DM is increasing over time, but the overall quality of lipid management is decreasing, as evidenced by documented testing, treatment and control of LDL-C. In order to realise the full evidence-based benefit from LLT, improvement in the implementation of guideline-recommended care is required.

The Registry of Fast Myocardial Perfusion Imaging with Next-Generation SPECT (REFINE SPECT) has been expanded to include more patients and CT attenuation correction imaging. We present the design and initial results from the updated registry. Methods: The updated REFINE SPECT is a multicenter, international registry with clinical data and image files. SPECT images were processed by quantitative software and CT images by deep learning software detecting coronary artery calcium (CAC). Patients were followed for major adverse cardiovascular events (MACEs) (death, myocardial infarction, unstable angina, late revascularization). Results: The registry included scans from 45,252 patients from 13 centers (55.9% male, 64.7 ± 11.8 y). Correlating invasive coronary angiography was available for 3,786 (8.4%) patients. CT attenuation correction imaging was available for 13,405 patients. MACEs occurred in 6,514 (14.4%) patients during a median follow-up of 3.6 y (interquartile range, 2.5-4.8 y). Patients with a stress total perfusion deficit of 5% to less than 10% (unadjusted hazard ratio [HR], 2.42; 95% CI, 2.23-2.62) and a stress total perfusion deficit of at least 10% (unadjusted HR, 3.85; 95% CI, 3.56-4.16) were more likely to experience MACEs. Patients with a deep learning CAC score of 101-400 (unadjusted HR, 3.09; 95% CI, 2.57-3.72) and a CAC of more than 400 (unadjusted HR, 5.17; 95% CI, 4.41-6.05) were at increased risk of MACEs. Conclusion: The REFINE SPECT registry contains a comprehensive set of imaging and clinical variables. It will aid in understanding the value of SPECT myocardial perfusion imaging, leverage hybrid imaging, and facilitate validation of new artificial intelligence tools for improving prediction of adverse outcomes incorporating multimodality imaging.

Abstract Background Patients with depression are at increased risk of future cardiovascular disease (CVD) events compared to those without depression. The reasons for this are not fully understood. Appropriate management of CVD risk factors, including blood pressure (BP) are essential for primary prevention of CVD. Purpose To explore whether there are differences in the likelihood of assessment, treatment and attainment of target levels of BP in patients with depression compared to those without. Methods A retrospective observational cohort study of patients without a history of depression or CVD was conducted using individual-level linked electronic health record data between 2010 & 2019 using the all-Wales SAIL Databank. Clinical codes were used to identify depression and hypertension diagnoses, BP assessments and antihypertensive therapy (AHT) from general practice (GP) data. Blood pressure assessment is presented as person year rates, and logistic regression was used to identify the likelihood of treatment and control of BP (<140/<90mmHg). Results A total of 2,290,075 patients were included (47% female & 7.7% depressed). Depressed patients were younger than non-depressed (mean age 32.0±15.5 vs 40.7±19.3 yrs respectively). Blood pressure assessment rates (BP checks per person per year) were greater in patients with depression 0.813 (0.811-0.815) vs 0.621 (0.620-0.621). Assessment was most frequent in depressed women (0.988 [0.985-0.991]) and least in non-depressed males (0.490 [0.489-0.490]). In patients with a history of HTN, GP diagnosis or high BP reading (n=738,164), 265,232 (35.9%) were on AHT within one year; a smaller proportion of depressed patients with hypertension were receiving AHT than non-depressed (23,808 [34.0%] vs 241,424 [36.1%] p<0.001). However, after multiple logistic regression (adjusting for age, sex, location of residence, deprivation, and comorbidities), depressed patients were more likely to be on AHT (OR 1.22 95%CI 0.12-1.32). In those patients on AHT 235,134 (88.7%) had at least one valid BP measurement during the year. Of these 114,601 (48.7%) achieved a BP <140/90 mmHg. A greater proportion of depressed patients with hypertension on AHT had documented control of BP than non-depressed (11,143 [57.3%] vs 103,458 [48.0%] p<0.001 OR 1.28 95%CI 1.11-1.50). There was a significant interaction between depression and sex, with depressed females being the most likely to achieve control (p<0.001). Conclusion Patients with depression are more likely to have BP assessed and to have hypertension treated and controlled than patients without depression within Welsh primary care. This maybe due to more frequent interaction with their GP, but further research is required to investigate reasons and impact on outcomes.

BACKGROUND:This study estimated to what extent the number of measurements of cardiometabolic risk factors (e.g., blood pressure, cholesterol, glycated haemoglobin) were impacted by the COVID-19 pandemic and whether these have recovered to expected levels. METHODS AND FINDINGS:A cohort of individuals aged ≥18 years in England with records in the primary care-COVID-19 General Practice Extraction Service Data for Pandemic Planning and Research (GDPPR) were identified. Their records of 12 risk factor measurements were extracted between November 2018 and March 2024. Number of measurements per 1,000 individuals were calculated by age group, sex, ethnicity, and area deprivation quintile. The observed number of measurements were compared to a composite expectation band, derived as the union of the 95% confidence intervals of 2 estimates: (1) a projected trend based on data prior to the COVID-19 pandemic; and (2) an assumed stable trend from before pandemic. Point estimates were calculated as the mid-point of the expectation band. A cohort of 49,303,410 individuals aged ≥18 years were included. There was sharp drop in all measurements in March 2020 to February 2022, but overall recovered to the expected levels during March 2022 to February 2023 except for blood pressure, which had prolonged recovery. In March 2023 to March 2024, blood pressure measurements were below expectation by 16% (-19 per 1,000) overall, in people aged 18 to 39 (-23%; -18 per 1,000), 60 to 79 (-17%; -27 per 1,000), and ≥80 (-31%; -57 per 1,000). There was suggestion that recovery in blood pressure measurements was socioeconomically patterned. The second most deprived quintile had the highest deviation (-20%; -23 per 1,000) from expectation compared to least deprived quintile (-13%; -15 per 1,000). CONCLUSIONS:There was a substantial reduction in routine measurements of cardiometabolic risk factors following the COVID-19 pandemic, with variable recovery. The implications for missed diagnoses, worse prognosis, and health inequality are a concern.

Abstract Background United Kingdom guidelines (NICE, NG106) for suspected chronic heart failure (HF) recommend that NT pro-BNP is performed as a first-line test. The result is also used to triage individuals; when NT pro-BNP is <400ng/L, a diagnosis of HF is less likely, echocardiography (echo) and specialist assessment should be performed within 6 weeks when the result is 400-2000ng/L, and within 2 weeks if >2000ng/L. How accurately this guidance is followed in clinical practice in Wales is not known. Purpose To examine how the current diagnostic pathway is recorded in routinely-collected electronic health record (EHR) data for older people in Wales with a diagnosis of heart failure. Methods We conducted a retrospective, population-level, observational study using linked anonymised EHR data in Wales (2015-22). We included patients aged 65y+ with a HF diagnosis in their primary or secondary care records and with a minimum of 12m pre and post-diagnosis data (for assessment of diagnostic pathway). We looked back from the point of HF diagnosis for codes associated with prior cardiovascular conditions (any time prior), symptoms (within 3 years), and key diagnostic tests (within 90 days). Results The final cohort comprised 51,020 individuals 65y and over with a diagnosis of heart failure between 2015-2022. Incidence and prevalence of heart failure increased across the study period (1.4-1.5% and 8.5-9.1% respectively). HF diagnosis was first evident in secondary care records in 54.9%, in primary care 36.3%, and in both data sources on the same day in 8.8%. Preceding cardiovascular diagnoses included hypertension (69.5%), atrial fibrillation (36.7%), myocardial infarction (30.5%), coronary artery disease (25.7%), and valve disease (17.7%). The most common recorded symptoms preceding diagnosis were breathlessness (41.4%), ankle oedema (9.8%), and fatigue (8.8%). Searched for symptoms were not recorded in 43.8%. In the 90 days preceding the diagnosis, 7-30% had recorded NT pro-BNP with the number of tests increasing throughout the study period (Figure 1). In the 90 days prior to HF diagnosis, 28-31% had an echo recorded. NT pro-BNP was >2000ng/L in 51.8%, 400-2000ng/L in 38.6% and <400ng/L in 9.6%. Conclusions In Wales, a greater number of individuals with heart failure appear to be diagnosed during hospital admission, compared with primary care. Many individuals with a code for HF in their records, do not have recorded objective evidence of cardiac dysfunction. The proportion of first-line and definitive tests appears low. It is unclear whether this is because of under-referral, difficulty accessing tests in primary care, or inaccurate coding of test referrals and results. These results are important in evaluating health service delivery and workforce planning.