BACKGROUND:Despite treatment, many hypertensive patients with coronary heart disease (CHD) have blood pressure (BP) that remains above guideline targets. However, less is known about patients in whom on-treatment BP is below target and major European guidelines differ substantially in their recommendations for such patients. Specifically, 2023 European Society of Hypertension (ESH) guidelines provide a Class 3 recommendation to proactively avoid BP below target whereas 2024 European Society of Cardiology (ESC) guidelines do not. METHODS:Between 2020 and 2023, adults hospitalised in the previous 6-24 months with incident or recurrent CHD were sampled in 14 countries from all six WHO regions and invited for a standardised interview and examination as part of the International Action on Secondary and Primary Prevention by Intervention to Reduce Events (INTERASPIRE) study. We measured seated BP twice using an automated oscillometric device after 5 min of rest. We defined participants as having BP above target (BP ≥130/80 mm Hg), at target (BP 120-129/70-79 mm Hg) or below target (<120/70 mm Hg); according to both 2023 ESH and 2024 ESC guidelines. RESULTS:Among 4548 participants (21.1% female), the mean age (±SD) was 60.0 (±10.3) years. At a median (IQR) of 1.05 (0.76-1.45) years after index CHD hospitalisation, 10.3% of patients had BP readings within the target range of 120-129/70-79 mm Hg, with 53.9% above target and 35.7% below target. Patients with below-target BP were more likely to have heart failure (13.6% vs 10.0%, p=0.041) and estimated glomerular filtration rate <60 mL/min/1.73 m² (18.9% vs 10.7%, p<0.001), when compared with those at target. They were also statistically more likely to be severely frail (p=0.030). The median number of BP-lowering medications did not differ significantly between the 3 BP target groups. Cumulative dosing of BP-lowering medications in the below-target group was also not more intensive than that in the at-target group. CONCLUSIONS:More than one-third of INTERASPIRE patients with CHD presented with BP <120/70 mm Hg, which is below target per current European hypertension guidelines. Further research is needed in this population to resolve discordant guideline recommendations and determine whether de-escalation of BP-lowering therapies is beneficial or even harmful in this setting.

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.

OBJECTIVES:Rivaroxaban 2.5mg twice daily with aspirin 100mg daily was superior to aspirin 100mg daily in the COMPASS trial but the cost-effectiveness in Scandinavia is unknown. DESIGN:Mean lifetime costs (USDs) and quality-adjusted life-years were determined from a Scandinavian perspective using a 2-state Markov model with US mortality data. Subgroup and sensitivity analyses were performed. RESULTS:Over a lifetime adding rivaroxaban to aspirin had lower costs (-$3791USD/-23675DKK/-27410NOK/-29200SEK) and gained 1.17 QALYs versus ASA alone. CONCLUSION:Rivaroxaban 2.5mg twice daily with aspirin is a dominant strategy compared to aspirin alone in COMPASS participants from a Scandinavian perspective.

International guidelines define standards of care for type 2 diabetes (T2D), obesity, cardiovascular disease (CVD), metabolic dysfunction-associated steatotic liver disease (MASLD) and chronic kidney disease (CKD). Yet implementation at the national level remains inconsistent, leading to persistent gaps between evidence-based recommendations and real-world practice. Key barriers include linguistic and cultural adaptation, limited communication to clinicians, and siloed regulatory and reimbursement processes. Addressing these challenges requires coordinated strategies, such as concise translations, digital platforms and decision-support tools, integration into medical education, and structured monitoring and evaluation frameworks with feedback and incentives. Equitable and sustainable access further depends on coordination between medical societies, governmental authorities, payers, and patient representatives. Evidence from existing initiatives shows that systematic, context-sensitive approaches can measurably improve care. Building on these lessons, this Commentary recommends priorities for national implementation to ensure that guidelines move more effectively from publication to practice and realise their full potential to improve patient outcomes.

The primary analysis of the SELECT randomized clinical trial suggests that semaglutide reduced the rates of cardiovascular (CV) death, myocardial infarction, and stroke in patients with established CV disease (CVD) and overweight or obesity without diabetes. However, the effect of semaglutide on hospitalizations in this population remains unknown. To determine the impact of semaglutide on total hospital admissions and duration of hospital stay. The SELECT trial included patients aged 45 years or older with established CVD and a body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) of 27 or higher without diabetes at 804 clinical settings across North America, South America, Europe, Asia, Africa, and Australia. Patients were randomized from October 2018 to March 2021. This prespecified exploratory analysis was conducted from February 2024 to September 2025. Once-weekly subcutaneous semaglutide, 2.4 mg, or placebo. The total number of hospital admissions and days in hospital between the semaglutide and placebo groups. A total of 17 604 patients (median [IQR] age, 61.0 [55.0-68.0] years; 4872 female patients [27.7%]; median [IQR] BMI, 32.1 [29.7-35.7]) were followed up for a median (IQR) period of 41.8 (33.0-47.0) months. There were 11 287 hospital admissions. The number of total hospitalizations was lower in the semaglutide group vs placebo for any indication (18.3 vs 20.4 admissions per 100 patient-years; mean ratio [MR], 0.90; 95% CI, 0.85-0.95; P < .001) and for serious adverse events (15.2 vs 17.1 admissions per 100 patient-years; MR, 0.89; 95% CI, 0.84-0.94; P < .001). The number of days hospitalized for any indication per 100 patient-years was lower in the semaglutide group vs placebo (157.2 vs 176.2 days; rate ratio [RR], 0.89; 95% CI, 0.82-0.98; P = .01), as well as hospitalizations for serious adverse events (137.6 vs 153.9 days; RR, 0.89; 95% CI, 0.81-0.98; P = .02). No heterogeneity was observed for the reduction of hospital admissions with semaglutide in selected subgroups, including BMI, age, and sex. In this prespecified exploratory analysis of the SELECT randomized clinical trial, the trial cohort had a high rate of hospital admissions. Treatment with once-weekly semaglutide was associated with significant reductions in hospital admissions and overall time spent in hospital, extending its benefits beyond CV risk reduction. ClinicalTrials.gov Identifier: NCT03574597

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.

Background: Copeptin, a surrogate marker for vasopressin activity, is associated with cardiovascular disease, insulin resistance and glucose metabolism dysregulation. The cardioprotective effects of sodium-glucose cotransporter 2 inhibitors (SGLT2i) may involve vasopressin modulation through fluid redistribution, but whether this effect persists long-term in high-cardiovascular-risk patients with newly detected dysglycaemia remains unknown. Methods: In this post-hoc analysis of the SOCOGAMI double-blind, placebo-controlled trial, 42 patients (mean age 67.5 years, 19% female) with impaired glucose tolerance or newly diagnosed type 2 diabetes following an ACS and no heart failure were randomized to empagliflozin 25 mg/day (n=20) or placebo (n=22) for 7 months. Copeptin was serially measured during oral glucose tolerance tests (OGTT) at baseline, after 7 months on-treatment, and 3 months after treatment withdrawal. Treatment effects were assessed by repeated-measures ANOVA with treatment×time interaction and linear mixed-effects models. Results: Baseline copeptin did not differ between groups and correlated positively with arterial pulse wave velocity (r s =0.40, p=0.03), linking vasopressin activity to subclinical vascular stiffness. During treatment, a non-significant trend toward higher copeptin at 7 months in the empagliflozin group reversed to baseline after treatment discontinuation (treatment×time interaction p=0.64), with haematocrit showing a parallel non-significant pattern. Copeptin was not associated with the glucose-lowering effect of empagliflozin. No differential copeptin response during the OGTT across groups or visits was observed. Conclusions : Chronic empagliflozin treatment does not induce sustained vasopressin system activation in post-ACS patients with newly detected dysglycaemia and preserved cardiac function, suggesting physiological adaptation limits this response over time. These findings refine the mechanistic understanding of SGLT2i and provide a foundation for studies examining whether vasopressin modulation contributes to their cardiorenal benefits in specific high-risk subgroups. Trial registration number : EudraCT number 2015-004571-73.

BACKGROUND AND AIMS:This observational study investigated whether patients with coronary heart disease (CHD) in Europe are achieving the standards set by prevention and rehabilitation guidelines. Variability was studied: (i) between countries; (ii) between geographical risk regions; and (iii) attendance at cardiac rehabilitation (CR) with outcomes. METHODS:Observational study between September 2024- February 2026 in 160 hospitals across 27 countries. Geographical risk regions were defined as high, moderate or low based on WHO cardiovascular mortality data. RESULTS:Among 8590 patients with CHD (23.7% female), 17.1% were current smokers, 32.0% were obese and 33.5% reported low physical activity. 59.8% were above blood pressure target (systolic ≥ 130 and/or diastolic ≥ 80 mmHg), 82.7% were above LDL-C target (≥ 1.4 mmol/l), 32.8% had known diabetes of whom 42.2% had HbA1c ≥ 7% and 30.6% had chronic kidney disease. Prevalences of these risk factors were all highest in countries from high risk regions. 29.1% of patients attended at least one CR session, with country variability ranging from 0% to 79%, and differing by risk region (55.9% low risk, 29.7% moderate risk and 10.2% high risk; p < 0.001). Attendance at CR programme was associated with significantly better lifestyles, risk factor control and use of cardioprotective drugs. CONCLUSIONS:Most European patients are not achieving targets set by prevention guidelines. There is marked variability in CR attendance, evidence of inverse care with lowest attendance in highest risk regions, despite better outcomes for CR. These results inform the challenges for implementation of the first ESC guideline on CR.

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).

Copeptin, a surrogate marker for vasopressin secretion, is associated with cardiovascular disease, insulin resistance and dysglycaemia. The cardioprotective effects of sodium-glucose cotransporter 2 inhibitors (SGLT2i) may involve vasopressin modulation through fluid redistribution, but whether this effect persists long-term in high-cardiovascular-risk patients with newly detected dysglycaemia remains unknown. In this post-hoc analysis of the SOCOGAMI double-blind, placebo-controlled trial, 42 patients (mean age 67.5 years, 19

BACKGROUND:Lipoprotein(a) [Lp(a)] is a common risk factor for atherosclerotic cardiovascular disease, potentially more atherogenic per particle than low-density lipoprotein. An estimated 1.5 billion individuals globally have elevated levels ≥125 nmol/L, considered as a risk-enhancing threshold. Although Lp(a) levels vary by ethnicity, ongoing trials of novel therapies in predominantly secondary prevention patients use fixed Lp(a) enrollment thresholds. OBJECTIVES:The purpose of this study was to assess Lp(a) levels in coronary heart disease (CHD) patients across geographical regions, providing inference on the proportions potentially eligible for future Lp(a)-lowering therapies and whether these vary by region and country. METHODS:INTERASPIRE (International Action on Secondary Prevention through Intervention to Reduce Events)enrolled adults hospitalized with CHD in the previous 6 to 24 months. Lp(a) levels were available in 13 countries across 6 World Health Organization (WHO) regions: Africa (Kenya, Nigeria, Tanzania), Americas (Argentina, Colombia), Eastern Mediterranean (UAE), Europe (Poland, Portugal), South-East Asia (Indonesia), and Western Pacific (China, Malaysia, Philippines, Singapore). Lp(a) measurements were performed once and centrally in Helsinki using an isoform-independent assay for 11 countries, and locally in Indonesia and China with standardization to the core laboratory. Lp(a) levels are reported as median (Q1-Q3) and proportions above different thresholds. RESULTS:Lp(a) results were available for 3,928 patients from 13 countries (mean age: 60.2 ± 10.2 years; 21.1% women). Median Lp(a) was 32 nmol/L (Q1-Q3: 11-89 nmol/L) overall, with 17.6% having levels ≥125 nmol/L. Median levels varied by region-highest in Africa (62 nmol/L) and lowest in Western Pacific (22 nmol/L)-and also between countries within regions: Europe (Portugal: 59 nmol/L vs Poland: 19.5 nmol/L), South America (Colombia: 46 nmol/L vs Argentina: 32 nmol/L) and Western Pacific (Malaysia: 39.5 nmol/L vs Philippines: 14 nmol/L). Overall, the proportions of patients with Lp(a) ≥150, 175, and 200 nmol/L (hence eligibility for future Lp(a)-lowering therapies) were 13.0%, 9.3%, and 6.2%, respectively, with eligibility also varying among countries: highest in Portugal (25.5%, 18.3%, and 11.6%) and lowest in Philippines (4.3%, 2.5%, and 1.3%). CONCLUSIONS:The vast majority of patients with CHD have Lp(a) levels far below what is considered a typical risk-enhancing threshold, suggesting that the attributable risk from Lp(a) is more complex than previously perceived. Furthermore, wide geographical variations in Lp(a) levels above entry criteria for ongoing trials could impact equitable access to therapies, if these trials are positive.

Patients with type 2 diabetes have an increased risk of tachyarrhythmias and more frequently require implantable cardioverter defibrillators (ICD) than those without diabetes (No-DM). This study aims to investigate whether there is a difference in the indication, prognosis and complication rates for ICD-implantation between patients with and without type 2 diabetes in different ICD prevention groups. This Swedish retrospective cohort study included patients with de novo ICDs implanted between 2010 and 2021. Data from six national registries were analyzed to compare type 2 diabetes and No-DM patients regarding indications, complications, and outcomes (major adverse cardiovascular events [MACE], all-cause mortality). Subgroup analyses compared type 2 diabetes and No-DM by primary (PP) or secondary prevention (SP) ICD indication, and within the type 2 diabetes and No-DM groups (PP vs. SP). The study cohort consisted of 12,885 patients, including 2,843 with type 2 diabetes. Patients with diabetes had a mean age of 67.9 years and 85.4

AIMS:Anxiety and depression are associated with poor outcomes in patients with coronary heart disease (CHD), however their association with achieving recommended cardiovascular prevention standards is unclear. We examined this association across all World Health Organization regions. METHODS:Cross-sectional analysis of the INTERASPIRE study of adults hospitalized in the preceding 6 to 24 months with incident or recurrent CHD who underwent a standardized interview and examination (2020 to 2023) across 14 countries. The main outcome was the INTERASPIRE-Guideline Target Score (GTS); a 10-point assessment of achieving secondary prevention lifestyle, risk factor, and therapeutic targets. RESULTS:A total of 4546 patients (21.1% women) with a mean (SD) age of 60.0 (10.3) were interviewed. Prevalence's of anxiety and/or depression were greater in women than men, and prevalence of CHD lifestyle and behavioral risk factors increased alongside severity of anxiety and depression symptoms. Compared to those without symptoms, adjusted odds ratios for achieving a suboptimal INTERASPIRE-GTS were: 1.52 (95% CI 1.13-2.04, p = 0.006) for symptoms of depression; 1.57 (95% CI 1.09-2.26, p = 0.015) for 'possible' comorbid anxiety and depression; and 2.09 (95% CI 1.22-3.57, p = 0.007) for those with 'probable' comorbid anxiety and depression. CONCLUSION:Increasing severity of depression and anxiety symptoms are associated with reduced potential for achieving guideline standards for CHD secondary prevention. Secondary prevention programs should integrate risk-stratified management of individuals with symptoms of anxiety and/or depression to improve CHD guideline targets.

Recent clinical practice guidelines for diabetes, obesity, cardiovascular disease (CVD) and chronic kidney disease (CKD) emphasise a holistic, person-centred approach to care. However, they do not include recommendations for the assessment of patient-reported outcomes (PROs), which would – dependent on the topic of guideline – be important for improving shared decision-making, patients’ concordance with guideline recommendations, clinical outcomes and health-related quality of life (HRQoL). The Taskforce of the Guideline Workshop discussed PROs in diabetes, obesity, CVD and CKD as well as the relevance of their inclusion in clinical practice guidelines for the management of these conditions.

OBJECTIVE:To provide up-to-date evidence on key benefits, harms, and uncertainties regarding medications for adults with type 2 diabetes. DESIGN:Living systematic review and network meta-analysis (NMA), using frequentist random effects and GRADE (grading of recommendations, assessment, development and evaluation) approaches. Updates are planned at least two times a year. DATA SOURCES:Medline and Embase, searched up to 31 July 2024 for the current iteration. STUDY SELECTION:Randomised controlled trials of at least 24 weeks comparing one or more medications with standard treatment, placebo, or each other. RESULTS:The systematic review and NMA includes 493 168 participants from 869 trials (adding 53 trials since October 2022) reporting data for 13 drug classes (63 drugs) and 26 outcomes of interest. Regarding benefits, moderate to high certainty evidence confirms the well established cardiovascular and kidney benefits of sodium-glucose cotransporter-2 (SGLT-2) inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1RAs), and finerenone (the last for patients with established chronic kidney disease). The most effective drugs in reducing body weight were tirzepatide (mean difference (MD) -8.63 kg (95% confidence interval -9.34 to -7.93); moderate certainty) and orforglipron (MD -7.87 kg (-10.24 to -5.50); low certainty), followed by eight other GLP-1RAs (high to moderate certainty). Absolute benefits of medications vary substantially depending on the baseline risk of cardiovascular and kidney outcomes; risk-stratified absolute effects of medications are summarised using an interactive multiple comparisons tool (https://matchit.magicevidence.org/250709dist-diabetes/#!/). Regarding medication-specific harms, SGLT-2 inhibitors increase genital infections (odds ratio (OR) 3.29 (95% CI 2.88 to 3.77); high certainty) and ketoacidosis due to diabetes (OR 2.08 (1.45 to 2.99); high certainty), and probably increase amputations (OR 1.27 (1.01 to 1.61); moderate certainty); tirzepatide and GLP-1RAs probably increase severe gastrointestinal events (most increased risk with tirzepatide (OR 4.21 (1.87 to 9.49); moderate certainty)); finerenone increases severe hyperkalaemia (OR 5.92 (3.02 to 11.62); high certainty); and thiazolidinediones increase major osteoporotic fractures and probably increase hospitalisation for heart failure. Sulfonylureas, insulin, and dipeptidyl peptidase-4 inhibitors probably increase the risk of severe hypoglycaemia. There is low to very low certainty evidence for effects on other diabetes-related complications, including neuropathy and visual impairment. Despite interest in the issue, there is uncertainty about whether GLP-1RAs may reduce dementia (OR 0.92 (0.83 to 1.02); low certainty). CONCLUSIONS:This living systematic review provides a comprehensive summary of the cardiovascular, kidney, and weight loss benefits, as well as medication-specific harms of medications for adults with type 2 diabetes, including effects of SGLT-2 inhibitors, GLP-1RAs, finerenone and tirzepatide. SYSTEMATIC REVIEW REGISTRATION:PROSPERO number: CRD42022325948. A more detailed protocol is available at https://data.aliveevidence.org/records/q02rv-km486. READERS' NOTES:This article is the first version of a living systematic review. It is linked to a living BMJ Rapid Recommendation and other living clinical practice guidelines, presenting risk stratified recommendations for patients with type 2 diabetes at lower, moderate, and higher risk of cardiovascular and kidney complications. The latest evidence will be made available via the BMJ Rapid Recommendation and via an interactive GRADE evidence summary (MATCH-IT: https://matchit.magicevidence.org/250709dist-diabetes/#!/). Major updates will be published in The BMJ.

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

AIMS:To quantify international variations in lipid-lowering therapies (LLT) use among patients with coronary heart disease (CHD) and attainment of European guideline-recommended lipid goals. METHODS AND RESULTS:INTERASPIRE is an observational study (2020-23) covering 14 countries from all WHO regions. Patients (18-79 years) hospitalized in the preceding 6-36 months with CHD were invited for standardized interviews and examination, with central laboratory analyses for low-density lipoprotein cholesterol (LDL-C), non-HDL-C, and apolipoprotein B (apoB). Valid lipid data meeting quality control standards were available from 13 countries. Lipid goals followed the 2019 guidelines of the European Atherosclerosis Society and the European Society of Cardiology: LDL-C < 1.4 mmol/L, non-HDL-C < 2.2 mmol/L, and apoB <65 mg/dL.Among 4061 patients (78.8% male, mean age 60.3 years), between index event and interview, 66.3% had no change in treatment intensity. LLT use at interview was largely statin monotherapy: 49.6% high-intensity (inter-country range 5.3%-77.3%) and 24.1% low/moderate-intensity (inter-country range 5.1%-70.1%). Otherwise, 12.2% (inter-country range 0.2%-41.1%) were on combination therapy, and 12.7% on no LLT (inter-country range 3.5%-36.7%). Goal attainment for LDL-C was 17.5%. Corresponding non-HDL-C and apoB goals were achieved by 29.9% and 29.2%, respectively. Higher-income countries (defined by the World Bank's 2024-25 classification of income levels) did better in goal attainment than lower-middle-income countries. CONCLUSION:In this international study, contemporary lipid goals were not achieved in most CHD patients, with lower-middle-income countries having the worst goal attainment. Contributory factors include absence of any LLT use, low use of combinations and a failure to up-titrate LLT to achieve guideline targets.

Background:INTERASPIRE was an observational study of patients with coronary heart disease (CHD) from 88 hospitals in 14 countries across all six WHO regions. The objective was to describe the proportions of patients referred to and attending cardiac rehabilitation (CR) programmes and to compare lifestyle and risk factor target achievement according to participation in a CR programme. Methods:Patients 18-80 years of age, with a first or recurrent coronary hospitalisation (acute coronary syndrome and/or revascularisation procedure) were identified and invited to an interview and examination, between six months and two years after the index hospitalisation. Results:Overall, 4,548 (21.1% female) patients were interviewed a median of 1.05 (interquartile range 0.76-1.45) years after hospitalization. Of those patients, 34.4% reported having been advised to participate in a CR programme, though the percentage varied widely by country, from 4.0% in Kenya to 69.6% in Poland. Among patients advised to participate in CR, 57.1% participated in ≥50% of all sessions, 15.4% participated in <50% of the sessions, and 27.4% did not participate at all. Only 19.6% of all patients recruited to the study attended ≥50% of sessions. Content of programmes reported by patients also varied enormously between countries. Low education level, elective PCI, or unstable angina as recruiting events were associated with lower attendance rates. Attendance at ≥50% of all CR sessions was associated with a lower prevalence of persistent smoking and physical inactivity, better control of blood pressure and LDL-cholesterol, and a higher use of cardioprotective medications. Conclusions:INTERASPIRE provides a standardised international picture of CR provision and attendance in patients with CHD. Despite CR being a Class 1 recommendation in all international guidelines, only one third of CHD patients reported being advised to attend any form of CR and just one in five patients attended 50% of the sessions, with striking heterogeneity between regions and countries. National cardiology societies should advocate to their governments for urgent investment in standardised CR services.