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Background: UK cardiovascular disease (CVD) incidence and mortality have declined in recent decades but socioeconomic inequalities persist. Aim: To present a new CVD model, and project health outcomes and the impact of guideline-recommended statin treatment across quintiles of socioeconomic deprivation in the UK. Design and setting: A lifetime microsimulation model was developed using 117 896 participants in 16 statin trials, 501 854 UK Biobank (UKB) participants, and quality-of-life data from national health surveys. Method: A CVD microsimulation model was developed using risk equations for myocardial infarction, stroke, coronary revascularisation, cancer, and vascular and non-vascular death, estimated using trial data. The authors calibrated and further developed this model in the UKB cohort, including further characteristics and a diabetes risk equation, and validated the model in UKB and Whitehall II cohorts. The model was used to predict CVD incidence, life expectancy, quality-adjusted life years (QALYs), and the impact of UK guideline-recommended statin treatment across socioeconomic deprivation quintiles. Results: Age, sex, socioeconomic deprivation, smoking, hypertension, diabetes, and cardiovascular events were key CVD risk determinants. Model-predicted event rates corresponded well to observed rates across participant categories. The model projected strong gradients in remaining life expectancy, with 4–5-year (5–8 QALYs) gaps between the least and most socioeconomically deprived quintiles. Guideline-recommended statin treatment was projected to increase QALYs, with larger gains in quintiles of higher deprivation. Conclusion: The study demonstrated the potential of guideline-recommended statin treatment to reduce socioeconomic inequalities. This CVD model is a novel resource for individualised long-term projections of health outcomes of CVD treatments. [ABSTRACT FROM AUTHOR]

Background: Heart failure is a major burden in Australia in terms of morbidity, mortality and healthcare expenditure. Multiple evidence‐based therapies are recommended for heart failure with reduced ejection fraction (HFrEF), but data on physician adherence to therapy guidelines are limited. Aim: To compare use of HFrEF therapies against current evidence‐based guidelines in an Australian hospital inpatient population. Methods: A retrospective review of patients admitted with a principal diagnosis of HFrEF across six metropolitan hospitals in Sydney, Australia, between January 2015 and June 2016. Use of medical and device therapies was compared with guideline recommendations using individual patient indications/contraindications. Readmission and mortality data were collected for a 1‐year period following the admission. Results: Of the 1028 HFrEF patients identified, 39 were being managed with palliative intent, leaving 989 patients for the primary analysis. Use of beta‐blockers (87.7% actual use/93.6% recommended use) and diuretics (88.4%/99.3%) was high among eligible patients. There were large evidence‐practice gaps for angiotensin‐converting enzyme inhibitors/angiotensin II receptor blockers (ACEI/ARB; 66.4%/89.0%) and aldosterone antagonists (41.0%/77.1%). In absolute terms, use of these therapies each increased by over 11% from admission. Ivabradine (11.5%/21.2%), automated internal cardiac defibrillators (29.5%/66.1%) and cardiac resynchronisation therapy (13.1%/28.7%) were used in a minority of eligible patients. Over the 1‐year follow‐up period, the mortality rate was 14.8%, and 44.2% of patients were readmitted to hospital at least once. Conclusion: Hospitalisation is a key mechanism for initiation of HFrEF therapies. The large evidence‐practice gaps for ACEI/ARB and aldosterone antagonists represent potential avenues for improved HFrEF management. [ABSTRACT FROM AUTHOR]

Aims To undertake a systematic review and meta-analysis to determine the influence of tricuspid regurgitation (TR) severity on mortality. Methods and results We performed a systematic search for studies reporting clinical outcomes of patients with TR. The primary endpoint was all-cause mortality and secondary endpoints were cardiac mortality and hospitalization for heart failure (HF). Overall risk ratios (RR) and 95% confidence intervals (CIs) were derived for each endpoint according to the severity of TR by meta-analysing the effect estimates of eligible studies. Seventy studies totalling 32 601 patients were included in the analysis, with a mean (±SD) follow-up of 3.2 ± 2.1 years. Moderate/severe TR was associated with a two-fold increased mortality risk compared to no/mild TR (RR 1.95, 95% CI 1.75–2.17). Moderate/severe TR remained associated with higher all-cause mortality among 13 studies which adjusted for systolic pulmonary arterial pressures (RR 1.85, 95% CI 1.44–2.39), and 15 studies, which adjusted for right ventricular (RV) dysfunction (RR 1.78, 95% CI 1.49–2.13). Moderate/severe TR was also associated with increased cardiac mortality (RR 2.56, 95% CI 1.84–3.55) and HF hospitalization (RR 1.73, 95% CI 1.14–2.62). Compared to patients with no TR, patients with mild, moderate, and severe TR had a progressively increased risk of all-cause mortality (RR 1.25, 1.61, and 3.44, respectively; P  < 0.001 for trend). Conclusions Moderate/severe TR is associated with an increased mortality risk, which appears to be independent of pulmonary pressures and RV dysfunction. View large Download slide View large Download slide [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to identify positive and negative predictors of technical and clinical success for percutaneous coronary intervention (PCI) of chronic total occlusions (CTO).Methods: We conducted a systematic review and meta-analysis of studies published between 2000 and 2016 analysing rates of CTO PCI success with respect to demographic and angiographic characteristics. Crude ORs and 95% CIs for each predictor were calculated using a random effects model. Predictors of technical and clinical success were assessed among 28 demographic and 31 angiographic variables. Clinical success was defined as technical success without major adverse cardiac events.Results: A total of 61 studies, totalling 69 886 patients were included in this analysis. The major demographic characteristics associated with a 20% or greater reduction in the odds of technical and clinical success were a history of myocardial infarction, PCI, coronary artery bypass grafting, stroke/transient ischaemic attack and peripheral vascular disease. Angiographic factors were generally stronger predictors of reduced technical and clinical success. Those associated with >20% odds reduction included non-left anterior descending CTOs, multivessel disease, presence of bridging collaterals, moderate-to-severe calcification, >45 degree vessel bending, tortuous vessel, blunt stump and ostial lesions. Of these, novel predictors included prior PCI, prior stroke, peripheral vascular disease, presence of multivessel disease and bridging collaterals.Conclusion: The present study has identified strong negative predictors for clinical success for CTO PCI, which will aid in patient selection for this procedure. [ABSTRACT FROM AUTHOR]

Background: Whether statin therapy is as effective in women as in men is debated, especially for primary prevention. We undertook a meta-analysis of statin trials in the Cholesterol Treatment Trialists' (CTT) Collaboration database to compare the effects of statin therapy between women and men.Methods: We performed meta-analyses on data from 22 trials of statin therapy versus control (n=134,537) and five trials of more-intensive versus less-intensive statin therapy (n=39,612). Effects on major vascular events, major coronary events, stroke, coronary revascularisation and mortality were weighted per 1.0 mmol/L reduction in LDL cholesterol and effects in men and women compared with a Cox model that adjusted for non-sex differences. For subgroup analyses, we used 99% CIs to make allowance for the multiplicity of comparisons.Findings: 46,675 (27%) of 174,149 randomly assigned participants were women. Allocation to a statin had similar absolute effects on 1 year lipid concentrations in both men and women (LDL cholesterol reduced by about 1.1 mmol/L in statin vs control trials and roughly 0.5 mmol/L for more-intensive vs less-intensive therapy). Women were generally at lower cardiovascular risk than were men in these trials. The proportional reductions per 1.0 mmol/L reduction in LDL cholesterol in major vascular events were similar overall for women (rate ratio [RR] 0.84, 99% CI 0.78-0.91) and men (RR 0.78, 99% CI 0.75-0.81, adjusted p value for heterogeneity by sex=0.33) and also for those women and men at less than 10% predicted 5 year absolute cardiovascular risk (adjusted heterogeneity p=0.11). Likewise, the proportional reductions in major coronary events, coronary revascularisation, and stroke did not differ significantly by sex. No adverse effect on rates of cancer incidence or non-cardiovascular mortality was noted for either sex. These net benefits translated into all-cause mortality reductions with statin therapy for both women (RR 0.91, 99% CI 0.84-0.99) and men (RR 0.90, 99% CI 0.86-0.95; adjusted heterogeneity p=0.43).Interpretation: In men and women at an equivalent risk of cardiovascular disease, statin therapy is of similar effectiveness for the prevention of major vascular events.Funding: UK Medical Research Council, British Heart Foundation, Australian National Health and Medical Research Council, European Community Biomed Program. [ABSTRACT FROM AUTHOR]

Background: Heart failure (HF) is a complex syndrome associated with high morbidity and mortality and increased health care use. Patient education is key to improving health outcomes, achieved by promoting self-management to optimize medical management. Newer digital tools like SMS text messaging and smartphone apps provide novel patient education approaches., Objective: This study aimed to partner with clinicians and people with lived experience of HF to identify the priority educational topic areas to inform the development and delivery of a bank of electronic-message driven tips (e-TIPS) to support HF self-management., Methods: We conducted 3 focus groups with cardiovascular clinicians, people with lived experience of HF, and their caregivers, which consisted of 2 stages: stage 1 (an exploratory qualitative study to identify the unmet educational needs of people living with HF; previously reported) and stage 2 (a co-design feedback session to identify educational topic areas and inform the delivery of e-TIPS). This paper reports the findings of the co-design feedback session., Results: We identified 5 key considerations in delivering e-TIPS and 5 relevant HF educational topics for their content. Key considerations in e-TIP delivery included (1) timing of the e-TIPS; (2) clear and concise e-TIPS; (3) embedding a feedback mechanism; (4) distinguishing actionable and nonactionable e-TIPS; and (5) frequency of e-TIP delivery. Relevant educational topic areas included the following: (1) cardiovascular risk reduction, (2) self-management, (3) food and nutrition, (4) sleep hygiene, and (5) mental health., Conclusions: The findings from this co-design case study have provided a foundation for developing a bank of e-TIPS. These will now be evaluated for usability in the BANDAIDS e-TIPS, a single-group, quasi-experimental study of a 24-week e-TIP program (personalized educational messages) delivered via SMS text messaging (ACTRN12623000644662)., (© Caleb Ferguson, Scott William, Sabine M Allida, Jordan Fulcher, Alicia J Jenkins, Jo-Dee Lattimore, L-J Loch, Anthony Keech. Originally published in JMIR Cardio (https://cardio.jmir.org).)

Background: Heart failure (HF) is a complex syndrome associated with high morbidity and mortality and increased healthcare utilisation. Patient education is key to improving health outcomes, achieved by promoting self-management to optimise medical management. Newer digital tools like text messaging and smartphone applications provide novel patient education approaches., Objective: To partner with clinicians and people with lived experience of HF to identify the priority educational topic areas to inform the development and delivery of a bank of electronic-message driven tips ('e-TIPS') to support HF self-management., Methods: We conducted three focus groups with cardiovascular clinicians, people with lived experience of HF and their caregivers, which consisted of two stages: Stage 1 - an exploratory qualitative study to identify the unmet educational needs of people living with HF (previously reported) and Stage 2 - a co-design feedback session to identify educational topic areas and inform the delivery of e-TIPS. This paper reports the findings of the co-design feedback session., Results: We identified five key considerations in delivering e-TIPS and five relevant HF educational topics for their content. Key considerations in e-TIP delivery included: (i) Timing of the e-TIPS; (ii) Clear and concise e-TIPS; (iii) Embedding a feedback mechanism; (iv) Distinguishing actionable and non-actionable e-TIPS; and (v) Frequency of e-TIP delivery. Relevant educational topic areas included: (i) cardiovascular risk reduction; (ii) Self-management; (iii) Food and nutrition; (iv) Sleep hygiene; and (v) Mental health., Conclusions: The findings from this co-design case study have provided a foundation for developing a bank of e-TIPS. These will now be evaluated for usability in the BANDAIDS e-TIPS, a single group, quasi-experimental study of a 24-week e-TIP program (personalised educational messages) delivered via Short Message Service (ACTRN12623000644662).

Background: Statin therapy is effective for the prevention of coronary heart disease and stroke in patients with mild-to-moderate chronic kidney disease, but its effects in individuals with more advanced disease, particularly those undergoing dialysis, are uncertain., Methods: We did a meta-analysis of individual participant data from 28 trials (n=183 419), examining effects of statin-based therapy on major vascular events (major coronary event [non-fatal myocardial infarction or coronary death], stroke, or coronary revascularisation) and cause-specific mortality. Participants were subdivided into categories of estimated glomerular filtration rate (eGFR) at baseline. Treatment effects were estimated with rate ratio (RR) per mmol/L reduction in LDL cholesterol., Findings: Overall, statin-based therapy reduced the risk of a first major vascular event by 21% (RR 0·79, 95% CI 0·77-0·81; p<0·0001) per mmol/L reduction in LDL cholesterol. Smaller relative effects on major vascular events were observed as eGFR declined (p=0·008 for trend; RR 0·78, 99% CI 0·75-0·82 for eGFR ≥60 mL/min per 1·73 m(2); 0·76, 0·70-0·81 for eGFR 45 to <60 mL/min per 1·73 m(2); 0·85, 0·75-0·96 for eGFR 30 to <45 mL/min per 1·73 m(2); 0·85, 0·71-1·02 for eGFR <30 mL/min per 1·73 m(2) and not on dialysis; and 0·94, 0·79-1·11 for patients on dialysis). Analogous trends by baseline renal function were seen for major coronary events (p=0·01 for trend) and vascular mortality (p=0·03 for trend), but there was no significant trend for coronary revascularisation (p=0·90). Reducing LDL cholesterol with statin-based therapy had no effect on non-vascular mortality, irrespective of eGFR., Interpretation: Even after allowing for the smaller reductions in LDL cholesterol achieved by patients with more advanced chronic kidney disease, and for differences in outcome definitions between dialysis trials, the relative reductions in major vascular events observed with statin-based treatment became smaller as eGFR declined, with little evidence of benefit in patients on dialysis. In patients with chronic kidney disease, statin-based regimens should be chosen to maximise the absolute reduction in LDL cholesterol to achieve the largest treatment benefits., Funding: UK Medical Research Council, British Heart Foundation, Cancer Research UK, European Community Biomed Programme, Australian National Health and Medical Research Council, Australian National Heart Foundation., (Copyright © 2016 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY license. Published by Elsevier Ltd.. All rights reserved.)