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Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): EPIC Norfolk was supported by the Medical Research Council UK (programme grants numbers MRC G0401527, MRC G0701863, MRC G1000143) and Cancer Research UK (programme grant number CRUK 8257). Introduction The Systematic COronary Risk Evaluation 2 – Older Persons (SCORE2-OP) algorithm is developed to assess 10-year risk of fatal and non-fatal cardiovascular disease (CVD) in apparently healthy individuals aged ≥70 years. We evaluated the performance of SCORE2-OP in the European Prospective Investigation of Cancer Norfolk (EPIC-Norfolk) prospective population cohort. Purpose To validate the SCORE2-OP model in men and women aged 70-80 years without prior myocardial infarction or stroke. Methods We included individuals aged 70-80 without prior myocardial infarction or stroke. We compared SCORE2-OP (low-risk algorithm) calculated 10-year risk with 10-year observed event rates in the EPIC-Norfolk cohort. SCORE2-OP was calculated using baseline EPIC-Norfolk data (1993-1997). Cardiovascular events were defined as a composite outcome of (i) death due to ischemic heart disease, cardiac failure, cerebrovascular disease or peripheral-artery disease, (ii) non-fatal myocardial infarction or (iii) non-fatal stroke. Observed rates were adjusted for competing fatal events. We evaluated discriminative power using C-statistic and calibration by plotting predicted versus observed event rates and calculating the observed/predicted ratios. Results SCORE2-OP was evaluated in 3,712 individuals (54% women) with a median (IQR) age of 73 (72-75) years. Ten-year SCORE2-OP was 10.3% (95% confidence interval (CI) 10.2-10.4) versus observed CVD of 16.8% (95% CI 15.6-18.0), yielding a ratio of 1.6 (95% CI 1.5-1.7). Observed events consisted of 9.4% (95% CI 8.4-10.3) fatal CVD events, 10.6% (95% CI 9.6-11.5) non-fatal myocardial infarctions, 10.5% (95% CI 9.5-11.5) non-fatal strokes, adjusted for 68.9% (95% CI 67.4-70.4) competing mortality events. C-statistic was 0.60 (95% CI 0.58-0.63), with a calibration plot demonstrating underestimation of risk across sex and risk groups.(Figure). Conclusion SCORE2-OP underestimates risk in individuals aged 70-80 years, and demonstrates suboptimal discriminative ability. However some underestimation of risk is to be expected given the EPIC-Norfolk baseline between 1993-1997, a low SCORE2-OP calculated risk should not be used as a standalone argument to withhold preventive efforts in older individuals.

Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): EPIC-Norfolk is supported by programme grants from the Medical Research Council UK (MRC G0401527, MRC G0701863, MRC G1000143) and Cancer Research UK (CRUK 8257). Introduction The latest European guidelines recommend the use of the Systematic COronary Risk Evaluation 2 (SCORE2) to assess 10-year risk of fatal and non-fatal cardiovascular disease (CVD) in individuals aged 40-70 years. Therefore, validation of the SCORE2 algorithm in a large population is needed. Purpose To assess the predictive performance of SCORE2 in individuals without prior myocardial infarction, stroke or diabetes mellitus. Methods Individuals aged 40-70 without prior myocardial infarction, stroke or diabetes mellitus were included from the European Prospective Investigation of Cancer Norfolk (EPIC-Norfolk) prospective population cohort. We assessed discriminative power using the C-statistic; calibration was assessed by plotting calculated SCORE2 (low-risk algorithm) 10-year risks against observed CVD event rates. We defined the composite cardiovascular outcome as death due to ischemic heart disease, cardiac failure, cerebrovascular disease or peripheral-artery disease, or non-fatal myocardial infarction or non-fatal stroke. Observed probabilities were adjusted for competing mortality events. Results We included 20,318 individuals (56% women) with a median (IQR) age of 56 (50-63) years, with baseline measures between 1993-1997. Mean predicted 10-year risk was 3.7% (95% confidence interval (CI) 3.7-3.8) versus adjusted observed 4.2% (95% CI 3.9-4.5) 10-year CVD incidence, yielding a ratio of 1.1 (95% CI 1.1-1.2).(Figure) Observed events consisted of 1.5% (95% CI 1.3-1.7) fatal CVD events, 1.8% (95% CI 1.6-2.0) non-fatal myocardial infarctions, 1.5% (95% CI 1.3-1.6) non-fatal strokes and 23.4% (95% CI 22.1-23.2) competing mortality events. Overall C-statistic was 0.75 (95% CI 0.73-0.77). Conclusion SCORE2 demonstrates reasonable discriminative ability and accurate risk estimations in low-risk individuals in a large, prospective population cohort. However, as actual CVD incidence is expected to be lower given the baseline between 1993-1997, these findings do not indicate that SCORE2 is suitable for current use for risk assessment in individuals from the United Kingdom.

Introduction Evidence on physical and psychological well-being of in-hospital cardiac arrest (IHCA) survivors is scarce. The aim of this study is to describe long-term health-related quality of life (HRQoL), functional independence and psychological distress 3 and 12 months post-IHCA. Methods A multicenter prospective cohort study in 25 hospitals between January 2017 – May 2018. Adult IHCA survivors were included. HRQoL (EQ-5D-5L, SF-12), psychological distress (HADS, CSI) and functional independence (mRS) were assessed at 3 and 12 months post-IHCA. Results At 3-month follow-up 136 of 212 survivors responded to the questionnaire and at 12 months 110 of 198 responded. The median (IQR) EQ-utility Index score was 0.77 (0.65–0.87) at 3 months and 0.81 (0.70–0.91) at 12 months. At 3 months, patients reported a median SF-12 (IQR) physical component scale (PCS) of 38.9 (32.8–46.5) and mental component scale (MCS) of 43.5 (34.0–39.7) and at 12 months a PCS of 43.1 (34.6–52.3) and MCS 46.9 (38.5–54.5). Discussion Using various tools most IHCA survivors report an acceptable HRQoL and a substantial part experiences lower HRQoL compared to population norms. Our data suggest that younger (male) patients and those with poor functional status prior to admission are at highest risk of impaired HRQoL.

Introduction: In-hospital cardiac arrest (IHCA) is an adverse event associated with high mortality. Because of the impact of IHCA more data is needed on incidence, outcomes and associated factors that are present prior to cardiac arrest. The aim was to assess one-year survival, patient-centred outcomes after IHCA and their associated pre-arrest factors. Methods: A multicentre prospective cohort study in 25 hospitals between January 1st 2017 and May 31st 2018. Patients ≥ 18 years receiving cardiopulmonary resuscitation (CPR) for IHCA were included. Data were collected using Utstein and COSCA-criteria, supplemented by pre-arrest Modified Rankin Scale (MRS, functional status) and morbidity through the Charlson Comorbidity Index (CCI). Main outcomes were survival, health-related quality of life (HRQoL, EuroQoL) and functional status (MRS) after one-year. Results: A total of 713 patients were included, 64.5% was male, median age was 63 years (IQR 52–72) and 72.8% had a non-shockable rhythm, 394 (55.3%) achieved ROSC, 231 (32.4%) survived to hospital discharge and 198 (27.8%) survived one year after cardiac arrest. Higher pre-arrest MRS, age and CCI were associated with mortality. At one year, patients rated HRQoL 72/100 points on the EQ-VAS and 69.7% was functionally independent. Conclusion: One-year survival after IHCA in this study is 27.8%, which is relatively high compared to previous studies. Survival is associated with a patient's pre-arrest functional status and morbidity. HRQoL appears acceptable, however functional rehabilitation warrants attention. These findings provide a comprehensive insight in in-hospital cardiac arrest prognosis.

Introduction Current primary prevention strategies in cardiovascular (CV) disease focus on initiating preventive interventions in people at high 10-year risk of CV mortality. However, initiating such strategies should be beneficial not only in the first 10 years, but throughout life. Established risk algorithms estimate the risk of 10-year CV mortality, but limited evidence is available about the relationship between 10-year and longer-term CV mortality. Purpose To compare cumulative incidence of CV mortality in a population cohort at 10- and 20-years follow-up, stratified by sex. Methods We analysed CV mortality at 10-years and 20-years follow-up using Kaplan-Meier estimates among men and women aged 39–70 years without baseline CV disease or diabetes mellitus in the large, prospective population-based EPIC-Norfolk cohort. CV mortality included death with as underlying or contributing cause ischaemic heart disease, heart failure, cerebrovascular disease or peripheral artery disease. Results We analysed data from 20,453 participants (56% women), with a mean age of 56±8 years, and median (IQR) follow-up of 22 (21–23) years. At baseline, there were no clinically relevant differences in CV risk factors between men and women. Overall cumulative CV mortality rate was 1.9% (384 deaths) in the first 10 years, and 7.3% (995 deaths) at 20 years follow-up (ratio 3.8). Among men, 10-year CV mortality was 2.9% (249 deaths), and 9.6% (785 deaths) at 20 years follow-up (ratio 3.3). Among women, CV mortality was 1.2% (135 deaths) at 10 year and 5.5% (594 deaths) at 20 years follow-up (ratio 4.6). Conclusion We observed an incremental increase in CV mortality beyond the 10-year scope of current established CV risk algorithms. At 20 years follow-up, CV mortality rates were 3–5 times higher compared with the first decade, indicating that 20-year CV mortality risk for both men and women cannot simply be estimated based on extrapolation of 10-year risk. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): EPIC-Norfolk is supported by programme grants from the Medical Research Council UK (MRC G0401527, MRC G0701863, MRC G1000143) and Cancer Research UK (CRUK 8257).

Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): NWO-grant Title (Dutch): Het centraal stellen van behandelvoorkeuren van de individuele patiënt met een chronische hartziekte. Subtitle: Persoonsgerichte zorg voor hartpatiënten Introduction Motivated patients are more likely to successfully improve unhealthy lifestyles. How patients perceive their risk factors and their willingness to improve is an integral part of this motivation. However, such preferences, and how they align with clinicians’ risk perception are seldom systematically assessed in patients with coronary artery disease (CAD). Purpose We aimed to investigate preferences in risk factor treatment in patients with CAD, and to compare this with clinicians’ perception of patients’ risks. Methods We administered a 10-item questionnaire on patients’ preferences on risk factor treatment in secondary prevention which was developed in consultation with end-users. We sent the questionnaire to approximately 450 patients who were referred to cardiac rehabilitation after recent ( Results A total of 296 patients completed the survey (66% of eligible respondents) at mean (SD) age 64 (10) years on median (IQR) 38 (25-53) days after discharge. Physical activity was much more frequently reported as risk factor by patients (P 55%) compared to clinicians (C 31%), followed by other disparities such as for high cholesterol (P 48% vs. C 36%) and overweight (P 46% vs. C 59%) (Figure 1). Patients were asked which of their perceived risk factors on Q1 was most important to improve (Q2) and for which they wanted help (Q3). Top-3 risk factors chosen for improvement were overweight (87%), physical inactivity (81%), and stress (79%), for which 75% required help with any risk factor, again most frequently with increasing physical activity (64%), overweight (59%) and stress (51%) (Figure 2). Motivation and confidence for improvement of risk factors were high: 87% were willing to adapt their lifestyles, with motivation rates of median (IQR) 8 (7-9) out of 10, and estimated chance for successful improvement of median (IQR) 7 (6-8) out of 10. Conclusion(s) Patients who recently suffered from coronary event are highly motivated to lose weight and increase physical inactivity. The use of these patient preferences by the clinician will enable compliance and outcomes with respect to weight loss and improved physical activity.

Background The decision to attempt or refrain from resuscitation is preferably based on prognostic factors for outcome and subsequently communicated with patients. Both patients and physicians consider good communication important, however little is known about patient involvement in and understanding of cardiopulmonary resuscitation (CPR) directives. Aim To determine the prevalence of Do Not Resuscitate (DNR)-orders, to describe recollection of CPR-directive conversations and factors associated with patient recollection and understanding. Methods This was a two-week nationwide multicentre cross-sectional observational study using a study-specific survey. The study population consisted of patients admitted to non-monitored wards in 13 hospitals. Data were collected from the electronic medical record (EMR) concerning CPR-directive, comorbidity and at-home medication. Patients reported their perception and expectations about CPR-counselling through a questionnaire. Results A total of 1136 patients completed the questionnaire. Patients’ CPR-directives were documented in the EMR as follows: 63.7% full code, 27.5% DNR and in 8.8% no directive was documented. DNR was most often documented for patients >80 years (66.4%) and in patients using >10 medications (45.3%). Overall, 55.8% of patients recalled having had a conversation about their CPR-directive and 48.1% patients reported the same CPR-directive as the EMR. Most patients had a good experience with the CPR-directive conversation in general (66.1%), as well as its timing (84%) and location (94%) specifically. Conclusions The average DNR-prevalence is 27.5%. Correct understanding of their CPR-directive is lowest in patients aged ≥80 years and multimorbid patients. CPR-directive counselling should focus more on patient involvement and their correct understanding.

While the beneficial effects of secondary prevention of cardiovascular disease are undisputed, implementation remains challenging. A gap between guideline-mandated risk factor targets and clinical reality was documented as early as the 1990s. To address this issue, research groups in the Netherlands have performed several major projects. These projects address innovative, multidisciplinary strategies to improve medication adherence and to stimulate healthy lifestyles, both in the setting of cardiac rehabilitation and at dedicated outpatient clinics. The findings of these projects have led to changes in prevention and rehabilitation guidelines.

Objective:Studies have reported an inverse association between a diet rich in fruits and vegetables and type 2 diabetes (T2D), but data on high-risk ethnic minority groups is limited. We investigated whether serum carotenoids, as biomarkers for fruit and vegetable intake, mediate ethnic differences in the prevalence of T2D.Design:Age-adjusted serum carotenoid concentrations were compared using ANCOVA. A cross-sectional analysis was performed using Cox regression to estimate prevalence ratios (PR) and their 95 % CI of the association between serum carotenoid concentrations and T2D. To study whether serum carotenoids potentially mediate the differences in the prevalence of T2D across ethnic groups, we compared PR of the model including known risk factors and the model additionally adjusted for serum carotenoid concentrations using the Dutch group as reference.Setting:A study among six ethnic groups living in Amsterdam, the Netherlands.Participants:Data on 204 Dutch, 203 South Asian Surinamese, 204 African Surinamese, 203 Turkish and 200 Moroccan-origin participants from the Healthy Life in an Urban Setting (HELIUS) study were used.Results:Serum carotenoid concentrations differed across ethnic groups. After adjusting for confounders, the serum concentrations of total carotenoids (PR 0·67, 95 % CI 0·54, 0·84), α-carotene (PR 0·57, 95 % CI 0·42, 0·77), β-carotene (PR 0·45, 95 % CI 0·32, 0·63) and β-cryptoxanthin (PR 0·73, 95 % CI 0·58, 0·92) were inversely associated with T2D. Despite the associations, serum carotenoids did not mediate the ethnic differences in the prevalence of T2D.Conclusions:The limited contribution of serum carotenoids to ethnic differences in T2D suggests that a focus on increasing fruit and vegetable intake alone will not likely eliminate ethnic differences in T2D prevalence.

Lifestyle management is the cornerstone of both primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD) and the importance of lifestyle management is emphasised by all major guidelines. Despite this, actual implementation of lifestyle management is poor. Lifestyle modification includes smoking cessation, weight loss, dietary change, increasing physical inactivity, and stress management. This review summarises evidence-based opportunities and challenges for healthcare professionals to promote healthy lifestyles at an individual level for the prevention of ASCVD.

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The high prevalence and burden of cardiovascular diseases (CVD) is largely attributable to unhealthy lifestyle factors such as smoking, alcohol consumption, physical inactivity and unhealthy food habits. Prevention of CVD, through the promotion of healthy lifestyles, appears to be a Sisyphean task for healthcare professionals, as the root causes of an unhealthy lifestyle lie largely outside their scope. Since most lifestyle choices are habitual and a response to environmental cues, rather than rational and deliberate choices, nationwide policies targeting the context in which lifestyle behaviours occur may be highly effective in the prevention of CVD. In this point-of-view article, we emphasise the need for government policies beyond those mentioned in the National Prevention Agreement in the Netherlands to effectively reduce the CVD risk, and we address the commonly raised concerns regarding ‘paternalism’. Supplementary Information The online version of this article (10.1007/s12471-021-01628-w) contains supplementary material, which is available to authorized users.

Objectives To determine the risk of first unplanned all-cause readmission and mortality of patients ≥70 years with acute myocardial infarction (AMI) or heart failure (HF) and to explore which effects of baseline risk factors vary over time. Methods A retrospective cohort study was performed on hospital and mortality data (2008) from Statistics Netherlands including 5,175 (AMI) and 9,837 (HF) patients. We calculated cumulative weekly incidences for first unplanned all-cause readmission and mortality during 6 months post-discharge and explored patient characteristics associated with these events. Results At 6 months, 20.4% and 9.9% (AMI) and 24.6% and 22.4% (HF) of patients had been readmitted or had died, respectively. The highest incidences were found in week 1. An increased risk for 14-day mortality after AMI was observed in patients who lived alone (hazard ratio (HR) 1.57, 95% confidence interval (CI) 1.01–2.44) and within 30 and 42 days in patients with a Charlson Comorbidity Index ≥3. In HF patients, increased risks for readmissions within 7, 30 and 42 days were found for a Charlson Comorbidity Index ≥3 and within 42 days for patients with an admission in the previous 6 months (HR 1.42, 95% CI 1.12–1.80). Non-native Dutch HF patients had an increased risk of 14-day mortality (HR 1.74, 95% CI 1.09–2.78). Conclusion The risk of unplanned readmission and mortality in older AMI and HF patients was highest in the 1st week post-discharge, and the effect of some risk factors changed over time. Transitional care interventions need to be provided as soon as possible to prevent early readmission and mortality. Electronic supplementary material The online version of this article (10.1007/s12471-019-1227-4) contains supplementary material, which is available to authorized users.

Introduction Interventions to reduce lifestyle-related risk factors (LRFs) such as overweight, physical inactivity and smoking are effective in the secondary prevention of cardiovascular events. However, evidence of the effects of lifestyle-related secondary prevention programmes in older patients with coronary artery disease (CAD) is less conclusive than in younger patients. Purpose To compare the treatment effect on lifestyle-related risk factors (LRFs) in older (≥65 years) versus younger ( Methods The RESPONSE-2 trial was a community-based lifestyle intervention trial (N=824) comparing nurse-coordinated referral to a comprehensive set of three lifestyle interventions (physical activity, weight reduction and/or smoking cessation) to care as usual. The primary outcome was the proportion of patients with improvement at 12 months follow-up (N=711) in at least 1 LRF (without deterioration in the other LRFs). In the current analysis, we assessed if the overall beneficial treatment effect of the RESPONSE-2 intervention varied by age. Results At baseline, older patients (n=245, 69.2±3.9) had significantly more serious cardiovascular risk profiles and comorbidities (hypertension, diabetes mellitus and peripheral artery disease) than younger patients (n=579, 53.7±3.9). The overall treatment effect did not vary by age (OR overall 1.67, 95% CI 1.22 - 2.31). However, older patients were more likely to achieve ≥5% weight loss (OR old 5.58, 95% CI 2.77–11.26 vs. OR young 1.57, 95% CI 0.98 - 2.49, P interaction=0.003) and younger patients were more likely to show non-improved individual LRFs (OR old 0.38, 95% CI 0.22–0.67 vs. OR young 0.88, 95% CI 0.61–1.26, P interaction=0.01). Conclusion Despite more serious cardiovascular risk profiles and comorbidities among older patients, nurse-coordinated referral to community-based lifestyle interventions was at least as successful in improving LRFs in older as in younger patients. Higher age alone should not be a reason to withhold lifestyle interventions in patients with CAD. LRFs at 12 months follow-up Funding Acknowledgement Type of funding source: Private company. Main funding source(s): The RESPONSE-2 trial was sponsored by Weight Watchers International, Inc. (New York, New York) and Philips Consumer Lifestyle (the Netherlands). This work was also supported by the Netherlands Organisation for Scientific Research (NWO) to PJ.

Background We performed an extended follow-up of the RESPONSE-2 trial, which evaluated a new secondary prevention strategy for patients with coronary artery disease (CAD). Selective loss to follow-up (LTFU) however, may induce biased results. Objectives To assess LTFU and its implications on the internal validity of the trial at extended follow-up. Methods RESPONSE-2 (N=824) was a randomised trial of nurse-coordinated referral of CAD patients to ≤3 commercial lifestyle interventions, on top of usual-care, or to usual-care alone. The primary outcome was assessed at 1-year follow-up, after which the interventions were discontinued. An extended follow-up was performed two years later. We evaluated overall selective LTFU, between-group selective LTFU and within-group selective LTFU, by comparing baseline characteristics, compliance with the lifestyle interventions (intervention group only) and achievement of lifestyle-related risk factor (LRF) targets at 1-year follow-up for attendees and non-attendees of the extended follow-up. In all variables a standardized mean difference (SMD) of ≥0.2 with a p-value Results In total, 520 patients attended the extended follow-up: 266/411 in the intervention and 254/413 in the control group. Patients LTFU were generally younger (56.5 vs. 59.3 years; SMD=0.299), more often baseline smokers (37% vs. 22%; SMD=0.334) and had less often quit smoking directly after hospitalization (17% vs. 25%; SMD=0.203). We found no evidence of between-group selective LTFU and several indications of within-group selective LTFU (table). Intervention group attendees were more compliant with the lifestyle interventions compared with non-attendees (weight loss: SMD=0.450; p≤0.05 and physical activity: SMD=0.516; p≤0.01) Conclusion Baseline LRF control, compliance with the lifestyle interventions and achievement of LRF targets were less favourable for non-attendees of the extended follow-up. Effective handling of missing data is recommended to minimize loss of contrast due to within-group selective LTFU and to ensure generalizability of results. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): The RESPONSE-2 trial was sponsored by Weight Watchers International, Inc. (New York, New York) and Philips Consumer Lifestyle (the Netherlands). The sponsors had no role in the design, data collection, data analysis, data interpretation, and writing of the manuscript.

Background Having a partner is associated with better prognosis in patients with cardiovascular disease. However, the influence of partners on modification of patients' lifestyle-related risk factors (LRFs) is unclear. Therefore, we studied the influence of partners and the level of partner participation on LRF modification in patients after an acute coronary syndrome (ACS) or revascularization. Methods The RESPONSE-2 trial was a community-based lifestyle intervention trial comparing nurse-coordinated referral to a comprehensive set of lifestyle interventions (physical activity, weight reduction and/or smoking cessation) to usual care. In the current analysis, we investigated the association of having a partner on the improvement in >1 LRF without deterioration in other LRFs at 12 months follow-up. Secondary, the influence of the level of partner participation (participating partner, non-participating partner and no partner) in the intervention group was studied. Results In total 824 individuals (411 intervention, 413 control) were included in the analysis. The presence of a partner was comparable in both groups (intervention 74%, control 69%). In the intervention group, 48% of partners participated in the lifestyle interventions. Overall, having a partner was positively associated with improvement in LRFs (odds ratio (OR) 2.57 (95% confidence interval (CI) 1.57–4.21), p Conclusion Having a partner is associated with improvement on LRFs in patients after ACS or revascularization. Moreover, patients with participating partners in the lifestyle programs were most successful in LRF modification. Involvement of partners in lifestyle interventions should be considered in routine practice. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Netherlands Organisation for Scientific Research (NWO)

Een substantieel deel van alle Nederlanders met een Turkse en Marokkaanse achtergrond (respectievelijk 21 % en 10 %) maakt gebruik van de gezondheidszorg in hun land van herkomst wanneer zij daar voor korte of langere tijd verblijven. Als dit ertoe leidt dat zij zorg mijden in de periode dat zij in Nederland zijn, dan zou het bezoeken van een arts in het land van herkomst een bedreiging kunnen zijn voor de continuiteit van zorg. Na koppeling van data van de HELIUS (HEalthy LIfe in an Urban Setting) studie aan zorgverzekeraarsdata, hebben wij de relatie tussen zorggebruik in het land van herkomst en zorggebruik in Nederland in de periode 2010–2015 onderzocht, onder Nederlanders met een Turkse of Marokkaanse achtergrond van 55 jaar en ouder, gecorrigeerd voor gezondheidsstatus als een indicator voor zorgbehoefte. In tegenstelling tot onze hypothese gebruiken Nederlanders met een Turkse en Marokkaanse achtergrond die gezondheidszorg in het land van herkomst gebruiken, in Nederland meer zorg dan degenen die geen gebruik maken van zorg in Turkije of Marokko. Onze resultaten geven daarom geen aanleiding om te denken dat het vermijden van zorg in Nederland een probleem vormt voor deze groep oudere migranten.

INTRODUCTION: Dutch cardiovascular disease (CVD) prevention guidelines recommend the use of modified SCORE risk charts to estimate 10-year risk of fatal and nonfatal CVD (myocardial infarction, cerebrovascular disease and congestive heart failure). This combined risk is derived from the SCORE mortality risk using multipliers. These multipliers have been shown to underestimate overall CVD risk. We aimed to compare the current Dutch risk charts with charts that estimate a broader range of clinically relevant CVD using updated multipliers. METHODS: We constructed new risk charts for 10-year CVD using updated, recently published multipliers from the EPIC-Norfolk study, based on ratios of fatal CVD to clinically relevant CVD (fatal plus nonfatal CVD requiring hospitalisation for ischaemic heart disease, cardiac failure, cerebrovascular disease, peripheral artery disease, and aortic aneurysm). Our primary outcome was the proportion of the three risk categories, i. e. 'high risk' (>20% 10-year risk), 'intermediate risk' (10-19%) and 'low risk' (

Background Hypertension disproportionately affects ethnic minority groups. Although health literacy may play role in these ethnic inequalities, little is known about the extent to which health literacy affects hypertension prevalence, awareness, treatment and control in different ethnic groups. Therefore, we assessed these associations in a multi-ethnic population. Methods Baseline data from the HELIUS study were used including participants of Dutch (n = 1948), South-Asian Surinamese (n = 2054) and African Surinamese (n = 1932) origin aged 18–70 years, who lived in Amsterdam, the Netherlands, were fluent in Dutch and underwent health literacy assessment through the Rapid Estimate of Adult Literacy in Medicine–Dutch (REALM-D). The REALM-D was categorized either as low ( Results After adjusting for confounding variables, Dutch [odds ratio (OR) 2.02; 95% confidence interval (CI), 1.11–3.64] and African Surinamese (OR 1.36; 1.03–1.79) with low health literacy were more likely than those with adequate health literacy to have hypertension, whereas in South-Asian Surinamese this association was not significant. No significant associations were found between health literacy and hypertension awareness, treatment and control in any of the ethnic groups. Conclusion Findings indicate that health literacy is associated with hypertension prevalence in selected ethnic groups, but not with hypertension awareness, treatment and control. Targeting health literacy might be an entry point for tackling ethnic inequalities in hypertension prevalence. To substantially reduce these inequalities, further research is needed to explore other factors and pathways through which health literacy may impact hypertension outcomes in different ethnic groups.

A substantial part of all Dutch people of Turkish and Moroccan origin use healthcare in the country of origin when travelling to their country of origin for a shorter or longer period of time (21% and 10%, respectively). If using care in the country of origin leads to avoidance of care in the Netherlands, this could threaten the continuity of care. We linked data of the HELIUS study to health insurance data. We examined the relationship between healthcare utilisation in the country of origin and the Netherlands, in the period of 2010-2015, adjusting for health status as an indicator of need. Contrary to our expectations, Dutch people of Turkish or Moroccan origin using healthcare consumption in the country of origin utilise more care in the Netherlands than individuals that do not utilize healthcare in the country of origin. Thus, our results do not provide any indication for avoidance of healthcare in the Netherlands among this group of older migrants in the Netherlands.

Background and aims Cardiovascular disease (CVD) risk factors may occur among a substantial proportion of normal weight individuals, particularly among some ethnic minorities. It is unknown how many of these individuals would be missed by commonly applied eligibility criteria for cardiovascular risk screening. Thus, we aim to determine cardiovascular risk and eligibility for cardiovascular risk screening among normal weight individuals of different ethnic backgrounds. Methods and results Using the HELIUS study (Amsterdam, The Netherlands), we determined cardiovascular risk among 6910 normal weight individuals of Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Moroccan and Turkish background. High cardiovascular risk was approximated by high metabolic risk based on blood pressure, HDL, triglycerides and fasting glucose. Eligibility criteria for screening were derived from Dutch CVD prevention guidelines and include age ≥ 50 y, family history of CVD, or current smoking. Ethnic group comparisons were made using logistic regression. Age-adjusted proportions of high metabolic risk ranged from 12.6% to 38.4% (men) and from 2.7% to 11.5% (women). This prevalence was higher among most ethnic minorities than the Dutch, especially among women. For most ethnic groups, 79.9%–86.7% of individuals with high metabolic risk were eligible for cardiovascular risk screening. Exceptions were Ghanaian women (58.8%), Moroccan men (70.9%) and Moroccan women (45.0%), although age-adjusted proportions did not differ between groups. Conclusion Even among normal weight individuals, high cardiovascular metabolic risk is more common among ethnic minorities than among the majority population. Regardless of ethnicity, most normal weight individuals with increased risk are eligible for cardiovascular risk screening.

This was a cross-sectional study in Amsterdam, the Netherlands. It included Dutch, African Surinamese and Ghanaian origin men and women (18-70 years) that participated in the multi-ethnic HELIUS study (n = 11,053). Body size ideals were assessed using a jumbled nine figure scale. Body satisfaction was calculated as the discrepancy between current and ideal silhouette. Acculturation proxies included age of migration, residence duration, ethnic identity and social network.

Background Ethnic differences have been reported in cardiovascular disease (CVD) risk factors. It is still unclear which ethnic groups are most at risk for CVD when all traditional CVD risk factors are considered together as overall risk. Objectives To examine ethnic differences in overall estimated CVD risk and the risk factors that contribute to these differences. Design Using data of the multi-ethnic HELIUS study (HEalthy LIfe in an Urban Setting) from Amsterdam, we examined whether estimated CVD risk and risk factors among those eligible for CVD risk estimation differed between participants of Dutch, South Asian Surinamese, African Surinamese, Ghanaian, Turkish and Moroccan origin. Using the Systematic COronary Risk Evaluation (SCORE) algorithm, we estimated risk of fatal CVD and risk of fatal plus non-fatal CVD. These risks were compared between ethnic groups via age-adjusted linear regression analyses. Results The SCORE algorithm was applicable to 9,128 participants. Relative to the fatal CVD risk of participants of Dutch origin, South Asian Surinamese participants showed a higher fatal CVD risk, Ghanaian males a lower fatal CVD risk, and participants of other ethnic origins a similar fatal CVD risk. For fatal plus non-fatal CVD risk, African Surinamese and Turkish men also showed a higher risk. When diabetes was incorporated in the CVD risk algorithm, all but Ghanaian men showed a higher CVD risk relative to the participants of Dutch origin (betas ranging from 0.98–3.10%). The CVD risk factors that contribute the most to these ethnic differences varied between ethnic groups. Conclusion Ethnic minority groups are at a greater estimated risk of fatal plus non-fatal CVD relative to the group of native Dutch. Further research is necessary to determine whether this will translate to ethnic differences in CVD incidence and, if so, whether ethnic-specific CVD prevention strategies are warranted. Electronic supplementary material The online version of this article (10.1007/s12471-018-1107-3) contains supplementary material, which is available to authorized users.

Background After hospitalization for cardiac disease, older patients are at high risk of readmission and death. Although geriatric conditions increase this risk, treatment of older cardiac patients is limited to the management of cardiac diseases. The aim of this study is to investigate if unplanned hospital readmission and mortality can be reduced by the Cardiac Care Bridge transitional care program (CCB program) that integrates case management, disease management and home-based cardiac rehabilitation. Methods In a randomized trial on patient level, 500 eligible patients ≥ 70 years and at high risk of readmission and mortality will be enrolled in six hospitals in the Netherlands. Included patients will receive a Comprehensive Geriatric Assessment (CGA) at admission. Randomization with stratified blocks will be used with pre-stratification by study site and cognitive status based on the Mini-Mental State Examination (15–23 vs ≥ 24). Patients enrolled in the intervention group will receive a CGA-based integrated care plan, a face-to-face handover with the community care registered nurse (CCRN) before discharge and four home visits post-discharge. The CCRNs collaborate with physical therapists, who will perform home-based cardiac rehabilitation and with a pharmacist who advices the CCRNs in medication management The control group will receive care as usual. The primary outcome is the incidence of first all-cause unplanned readmission or mortality within 6 months post-randomization. Secondary outcomes at three, six and 12 months after randomization are physical functioning, functional capacity, depression, anxiety, medication adherence, health-related quality of life, healthcare utilization and care giver burden. Discussion This study will provide new knowledge on the effectiveness of the integration of geriatric and cardiac care. Trial registration NTR6316. Date of registration: April 6, 2017. Electronic supplementary material The online version of this article (10.1186/s12913-018-3301-9) contains supplementary material, which is available to authorized users.

BackgroundCardiovascular disease (CVD) prevention guidelines stress the importance of smoking cessation and recommend intensive follow-up. To guide the development of such cessation support strategies, we analysed the characteristics that are associated with successful smoking cessation after an acute coronary syndrome (ACS).MethodsWe used data from the Randomised Evaluation of Secondary Prevention for ACS patients coordinated by Outpatient Nurse SpEcialists (RESPONSE) trial (n = 754). This was designed to quantify the impact of a nurse-coordinated prevention program, focusing on healthy lifestyles, traditional CVD risk factors and medication adherence. For the current analysis we included all smokers (324/754, 43 %). Successful quitters were defined as those who reported abstinence at 1 year of follow-up.ResultsThe majority of successful quitters quit immediately after the ACS event and remained abstinent through 1 year of follow-up, without extra support (128/156, 82 %). Higher education level (33 vs. 15 %, p p p ConclusionThe majority of successful quitters at 1 year stopped immediately after their ACS. Patients in this group showed that it was within their own ability to quit, and they did not relapse through 1 year of follow-up. Our study indicates that in a large group of patients who quit immediately after a life-threatening event, no relapse prevention program is needed.

A 57-year-old man of Turkish descent is treated for coronary artery disease. In addition to drug treatment and percutaneous revascularization, modification of lifestyle-related risk factors is indicated. His risk profile includes smoking, hypertension and inadequate physical activity. Adherence to medication is suboptimal and his wife is a smoker too. Limited health literacy and acculturation, and resource limitations impede adequate lifestyle changes. Guidance of this patient is challenging; it is not straightforward to influence the societal components of his issues from a medical office. Evidence-based lifestyle interventions are scarce, and their validation - if validated at all - was performed in populations that are not representative of the patient in question. However, physicians can contribute to achieving societal change by participating in national programs aimed at improving infrastructure, improving health literacy, development of ethnicity-specific interventions, availability of healthy food, discouragement of smoking, and creating an infrastructure that promotes physical activity in daily life.

OBJECTIVE: We investigated smoking cessation rates in coronary heart disease (CHD) patients throughout Europe; current and as compared to earlier EUROASPIRE surveys, and we studied characteristics of successful quitters.METHODS: Analyses were done on 7998 patients from the EUROASPIRE-IV survey admitted for myocardial infarction, unstable angina and coronary revascularisation. Self-reported smoking status was validated by measuring carbon monoxide in exhaled air.RESULTS: Thirty-one percent of the patients reported being a smoker in the month preceding hospital admission for the recruiting event, varying from 15% in centres from Finland to 57% from centres in Cyprus. Smoking rates at the interview were also highly variable, ranging from 7% to 28%. The proportion of successful quitters was relatively low in centres with a low number of pre- event smokers. Overall, successful smoking cessation was associated with increasing age (OR 1.50; 95% CI 1.09-2.06) and higher levels of education (OR 1.38; 95% CI 1.08-1.75). Successful quitters more frequently reported that they had been advised (56% vs. 47%, p CONCLUSION: Our study shows wide variation in cessation rates in a large contemporary European survey of CHD patients. Therefore, smoking cessation rates in patients with a CHD event should be interpreted in the light of pre-event smoking prevalence, and caution is needed when comparing cessation rates across Europe. Furthermore, we found that successful quitters reported more actions to make healthy lifestyle changes, including participating in a cardiac rehabilitation programme, as compared with persistent smokers.

Secondary prevention is an important part of cardiovascular risk management. Since 1996, an inventory of cardiovascular risk factors and their treatment has been carried out periodically among patients with coronary heart disease within the framework of the European Action on Secondary Prevention by Intervention to Reduce Events (Euroaspire) project.Retrospective investigation of consecutively hospitalised patients with coronary heart disease.Major cardiovascular risk factors and their treatment were investigated using standardised methods in patients who were hospitalised following a first heart infarction or with coronary revascularisation in the Amsterdam and Rijnmond regions of the Netherlands from 2012 to 2013. The investigations were carried out at an average of 18 months after admission. In addition, an oral glucose-tolerance test was carried out in patients without known diabetes.We studied 498 patients. The average BMI was 28 kg/m2, almost 75% had a BMI ≥ 25 kg/m2and 29% had a BMI ≥ 30 kg/m2. The mean cholesterol level was 4.4 mmol/l. Among those included, 16% smoked and 20% had diabetes mellitus; the oral glucose-tolerance test led to a new diabetes-mellitus diagnosis in 1% of the patients without known diabetes. A large majority of those included used antihypertensive agents, and slightly more than half used two or more medications. Despite this, half of the patients were hypertensive.As far as cardiovascular risk factors are concerned, smoking has almost halved in the past 20 years. Secondary preventative medication has increased to a stable high level. Blood pressure and overweight continue to be serious points for attention. Treatment of hypertension, in particular, should be improved, for instance by dose increases or combination of hypertensive medications. Routine oral glucose-tolerance tests are not useful in cardiac patients.

Evidence of ethnic disparities in the conversion of prediabetes to type 2 diabetes is scarce. We studied the association of impaired fasting glucose (IFG) and fasting plasma glucose (FPG) with the 10-year cumulative incidence of type 2 diabetes in three ethnic groups. We analyzed data for 90 South-Asian Surinamese, 190 African-Surinamese, and 176 ethnic Dutch that were collected in the periods 2001-2003 and 2011-2012. We excluded those with type 2 diabetes or missing FPG data. We defined baseline IFG as FPG of 5.7-6.9 mmol/L. We defined type 2 diabetes at follow-up as FPG ≥ 7.0 mmol/L, HbA1c ≥ 48 mmol/mol (6.5%), or self-reported type 2 diabetes. 10-Year cumulative incidences of type 2 diabetes were: South-Asian Surinamese, 18.9%; African-Surinamese, 13.7%; ethnic Dutch, 4.5% (p

The arterial endothelium is a complex organ that modulates vascular tone by release of various substances to control perfusion. Endothelial function reflects vascular ageing and health. Already at the earliest stages of atherosclerosis the delicate balance between arterial constriction and relaxation is disturbed. Therefore, non-invasive assessment of endothelial function is a means to identify patients at increased cardiovascular risk, even at levels of disease that cannot be identified with classical imaging techniques that depict arterial wall and/or lumen or with functional assessment of ischaemia. Currently, there is an increasing interest in the early recognition of endothelial dysfunction to streamline and optimise preventive therapeutic measures. In this article, several methods for the assessment of endothelial function are briefly reviewed. In particular, we discuss the fast bed-side assessment of endothelial function by the reactive hyperaemia peripheral arterial tonometry (RH-PAT) method.

To evaluate whether web-based interventions for cardiovascular risk factor management reduce the risk of cardiovascular disease in older people.Systematic review and meta-analysis.Embase, Medline, Cochrane Library and CINAHL were systematically searched from January 1995 to 3 November 2014. We included all randomised controlled trials for web-based interventions targeting cardiovascular risk factors in populations with a mean age of 50 and older. The outcome measures were cardiovascular risk factors (blood pressure, HbA1c, LDL cholesterol, weight, smoking status and physical activity) and the incidence of cardiovascular disease. We used random-effects models to pool the results of the studies.A total of 57 studies (19,862 participants) fulfilled eligibility criteria, and 47 of these were suitable for meta-analysis. We found a significant reduction in systolic blood pressure (-2.66 mmHg, 95% CI -3.81 to -1.52), diastolic blood pressure (-1.26 mmHg, 95% CI -1.92 to -0.60), HbA1c level (-0.13%, 95% CI -0.22 to -0.05), LDL cholesterol level (-0.06 mmol/l, 95% CI -0.10 to -0.01), weight (-1.34 kg, 95% CI -1.91 to -0.77), and an increase in physical activity (standardized mean difference 0.25, 95% CI 0.10-0.39) in the intervention group when compared with the control group. Treatment effects were more pronounced in studies of short duration (12 months) and when combining the web-based intervention with human support by a health care professional. No difference in the incidence of cardiovascular disease was found between groups.Web-based interventions have a beneficial effect on the cardiovascular risk profile, but this effect is modest and declines with time. Currently, there is insufficient evidence that this can prevent cardiovascular disease. A focus on long-term effects, effect-sustainability and clinical endpoints is recommended for future studies.

Background. Patients with coronary artery disease are at high risk of coronary events and death, but effective secondary prevention can reduce this risk. There is a gap between guidelines on secondary prevention and the implementation of these measures, which could potentially be reduced by nurse led prevention clinics (NLPC). Objectives. The aim of the current study is to quantify the impact of NLPC on the risk of cardiovascular events in patients with established coronary artery disease. Methods. A randomised, multicentre clinical trial of NLPC in addition to usual care or usual care alone in post-acute coronary syndrome patients. (Neth Heart J 2009;17:322-8.)

Background International studies suggest that many ethnic minority citizens use healthcare in their country of origin (CO). In the Netherlands, 12% of the population is of non-Western ethnic origin. A previous study showed that ethnic minority elderly use healthcare in the CO during holidays. Healthcare consumption in the country of origin (HCCO) may be …