Ineke van Dis

Background: GPs frequently use 10-year-risk estimations of cardiovascular disease (CVD) to identify high- risk patients.Aim: To assess the performance of four models for predicting the 10-year risk of CVD in Dutch general practice.Design and setting: Prospective cohort study. Routine data (2009– 2019) was used from 46 Dutch general practices linked to cause of death statistics.Method: The outcome measures were fatal CVD for SCORE and first diagnosis of fatal or non- fatal CVD for SCORE fatal and non-fatal (SCORE- FNF), Globorisk-laboratory, and Globorisk-office. Model performance was assessed by examining discrimination and calibration.Results: The final number of patients for risk prediction was 1981 for SCORE and SCORE-FNF, 3588 for Globorisk-laboratory, and 4399 for Globorisk- office. The observed percentage of events was 18.6% (n= 353) for SCORE- FNF, 6.9% (n= 230) for Globorisk-laboratory, 7.9% (n= 323) for Globorisk-office, and 0.3% (n= 5) for SCORE. The models showed poor discrimination and calibration. The performance of SCORE could not be examined because of the limited number of fatal CVD events. SCORE-FNF, the model that is currently used for risk prediction of fatal plus non-fatal CVD in Dutch general practice, was found to underestimate the risk in all deciles of predicted risks.Conclusion: Wide eligibility criteria and a broad outcome measure contribute to the model applicability in daily practice. The restriction to fatal CVD outcomes of SCORE renders it less usable in routine Dutch general practice. The models seriously underestimate the 10-year risk of fatal plus non-fatal CVD in Dutch general practice. The poor model performance is possibly because of differences between patients that are eligible for risk prediction and the population that was used for model development. In addition, selection of higher-risk patients for CVD risk assessment by GPs may also contribute to the poor model performance.

Background: To assess the trend in age- and sex-stratified mortality after hospitalization for heart failure (HF) in the Netherlands. Methods: Two nationwide cohorts of patients, hospitalized for new onset heart failure between 01.01.2000–31.12.2002 and between 01.01.2008–31.12.2010, were constructed by linkage of the Dutch Hospital Discharge Registry and the National Cause of Death registry. 30-day, 1-year and 5 -year overall and cause-specific mortality rates stratified by age and sex were assessed and compared over time. Results: We identified 40,230 men and 41,582 women. In both cohorts, men were on average younger than women (74–75 and 78–79 years, respectively) and more often had comorbid conditions (37 and 30%, respectively). In the 2008–10 cohort, mortality rates for men were 13, 32 and 64% for respectively 30-day, 1-year and 5-year mortality and 14, 33 and 66% for women. Mortality rates increased considerably with age similarly in men and women (e.g. from 10.5% in women aged 25–54 to 46.1% in those aged 85 and older after 1 year). Between the two time periods, mortality rates dropped across all ages, equally strong in women as in men. The 1-year absolute risk of death declined by 4.0% (from 36.1 to 32.1%) in men and 3.2% (from 36.2 to 33.0%) in women. Conclusions: Mortality after hospitalization for new onset HF remains high, however, both short-term and long-term survival is improving over time. This improvement was similar across all ages and equally strong in women as in men.

Favourable trends in risk factor levels in the general population may partly explain the decline in coronary heart disease (CHD) morbidity and mortality. Our aim was to present long-term national trends in established risk factors for CHD. Data were obtained from five data sources including several large scale population based surveys, cohort studies and general practitioner registers between 1988 and 2012. We applied linear regression models to age-standardized time trends to test for statistical significant trends. Analyses were stratified by sex and age (younger <65 and older ≥65 years adults). The results demonstrated favourable trends in smoking (except in older women) and physical activity (except in older men). Unfavourable trends were found for body mass index (BMI) and diabetes mellitus prevalence. Although systolic blood pressure (SBP) and total cholesterol trends were favourable for older persons, SBP and total cholesterol remained stable in younger persons. Four out of six risk factors for CHD showed a favourable or stable trend. The rise in diabetes mellitus and BMI is worrying with respect to CHD morbidity and mortality.

Background: Socioeconomic status has a profound effect on the risk of having a first acute myocardial infarction (AMI). Information on socioeconomic inequalities in AMI incidence across age- gender-groups is lacking. Our objective was to examine socioeconomic inequalities in the incidence of AMI considering both relative and absolute measures of risk differences, with a particular focus on age and gender. Methods: We identified all patients with a first AMI from 1997 to 2007 through linked hospital discharge and death records covering the Dutch population. Relative risks (RR) of AMI incidence were estimated by mean equivalent household income at neighbourhood-level for strata of age and gender using Poisson regression models. Socioeconomic inequalities were also shown within the stratified age-gender groups by calculating the total number of events attributable to socioeconomic disadvantage. Results: Between 1997 and 2007, 317,564 people had a first AMI. When comparing the most deprived socioeconomic quintile with the most affluent quintile, the overall RR for AMI was 1.34 (95 % confidence interval (CI): 1.32 – 1.36) in men and 1.44 (95 % CI: 1.42 – 1.47) in women. The socioeconomic gradient decreased with age. Relative socioeconomic inequalities were most apparent in men under 35 years and in women under 65 years. The largest number of events attributable to socioeconomic inequalities was found in men aged 45–74 years and in women aged 65–84 years. The total proportion of AMIs that was attributable to socioeconomic inequalities in the Dutch population of 1997 to 2007 was 14 % in men and 18 % in women. Conclusions: Neighbourhood socioeconomic inequalities were observed in AMI incidence in the Netherlands, but the magnitude across age-gender groups depended on whether inequality was expressed in relative or absolute terms. Relative socioeconomic inequalities were high in young persons and women, where the absolute burden of AMI was low. Absolute socioeconomic inequalities in AMI were highest in the age-gender groups of middle-aged men and elderly women, where the number of cases was largest.

About 30 years ago, the first Dutch unifactorial guidelines on hypertension and hypercholesterolaemia were developed. These guidelines have been revised several times, often after publication of landmark studies on new generations of drugs. In 1978, cut-off points for pharmacological treatment of hypertension were based on diastolic blood pressure values ≥115 mmHg, and in 2000 they were lowered to >100 mmHg. From 1997 onwards, cut-off points for systolic blood pressure values >180 mmHg were introduced, which became leading. In 1987, cut-offs for hypercholesterolaemia of ≥8 mmol/l were set and from 2006 pharmacological treatment was based on a total/HDL cholesterol ratio >8. Around 2000, treatment decisions for hypertension and/or hypercholesterolaemia were no longer based on high levels of individual risk factors, but on a multifactorial approach based on total risk of cardiovascular diseases (CVD), determined by a risk function. In the 2006 multidisciplinary guideline on cardiovascular risk management, the Framingham risk tables were replaced by European SCORE risk charts. A cut-off point of 10% CVD mortality was set in the Netherlands. In 2011, this cut-off point changed to 20% fatal plus nonfatal CVD risk. Nowadays, ‘the lower the risk factors, the lower the absolute risk’ is the leading paradigm in CVD prevention.

In clinical practice, individuals at increased risk of cardiovascular diseases (CVD) are identified on the basis of age, sex, smoking, blood pressure, and serum total and high-density lipoprotein cholesterol. We examined whether CVD risk prediction improved when obesity (body mass index ≥30 kg/m²) and premature (<70 years) parental myocardial infarction (MI) were added to the classical risk factor model. Risk factors were measured in 1993–97 in 12,818 participants (53% female) aged 35–65 in the Dutch MORGEN project. Cases of fatal and nonfatal CVD during 10 years of follow up were identified through record linkage. Classical risk factor equations, obtained by Cox proportional hazard analysis, were extended with obesity, paternal MI, and maternal MI. We calculated the net reclassification index (NRI), a measure for correct reclassification of subjects, to check improvement in risk prediction using 5 and 10% increments in absolute CVD risk. A CVD event occurred in 280 men and 140 women. Obesity and maternal MI were positively and significantly related to total CVD after adjustment for classical risk factors (both hazard ratios ∼1.5). Adding obesity and parental MI to CVD risk prediction yielded a significant NRI of 4.5% in men and a non-significant NRI of 2.6% in women when 5% risk categories were used. For 10% categories, the NRIs were slightly larger (5.5% and 3.3%, respectively). The improvements in risk prediction were mainly due to obesity. Modest improvements in CVD risk prediction can be obtained when obesity and, to a lesser extent, parental MI are added to the risk function.

European physicians use SCORE risk charts to predict a patient’s 10-year risk of cardiovascular diseases (CVD) mortality. We examined whether the inclusion of nonfatal events improved risk estimation and the identification of high-risk persons. In the EPIC-NL cohort, risk factor data were collected between 1993 and 1997 in 6772 men and 9108 women aged 35–65 years. During 10 years of follow up, 540 total (fatal + nonfatal) CVD events occurred, of which 122 (23%) were fatal. Risk equations were developed using Cox proportional hazard models. Discriminating ability and hazard ratios for CVD risk factors did not differ between the two endpoints. Absolute risks for total CVD were approximately 4-fold higher than for CVD mortality. Using the current 5% CVD mortality threshold or the 22% total CVD threshold for identification of high-risk persons leaves more than 84% of all male and 98% of all female future cases untreated. Of those exceeding these thresholds, 20% and 27% of the men, respectively, and 16% and 19% of women will get a CVD event in the next 10 years. Cut-off points of 2% for CVD mortality, corresponding to 10% for total CVD, will identify high-risk persons of whom approximately 10% will get an event in the next 10 years. CVD mortality comprises a quarter of all total CVD events. Risk functions and the discriminating ability did not differ between the two endpoints. Cut-off points of 2% for CVD mortality or 10% for total CVD could be considered to identify high-risk persons.

A positive parental history of myocardial infarction (MI) is an independent risk factor for cardiovascular diseases (CVD). However, different definitions of parental history have been used. We evaluated the impact of parental gender and age of onset of MI on CVD incidence. Baseline data were collected between 1993 and 1997 in 10 524 respondents aged 40–65 years. CVD events were obtained from the National Hospital Discharge Register and Statistics Netherlands. We used proportional hazard models to calculate hazard ratios (HR) and 95% confidence intervals (CI) for CVD incidence and adjusted for lifestyle and biological risk factors. At baseline, 36% had a parental history of MI. During 10-year follow-up, 914 CVD events occurred. The age and gender adjusted HR was 1.3 (95% CI 1.1–1.5) for those with a paternal MI, 1.5 (1.2–1.8) for those with a maternal MI and 1.6 (1.2–2.2) for those with both parents with an MI. With decreasing parental age of MI, HR increased from 1.2 (1.0–1.6) for age ≥70 years to 1.5 (1.2–1.8) for age <60 years for a paternal MI and from 1.1 (0.9–1.5) to 2.2 (1.6–3.0) for a maternal MI. The impact of having a mother with MI before age 60 significantly differed in women [(2.9 (1.8–4.6)] and men [1.5 (0.9–2.6)]. Adjustment only slightly influenced HRs for maternal MI. Respondents with a parental history of MI have an increased CVD incidence, in particular with parental onset of MI before age 70. A maternal history of MI before age 60 was the strongest predictor of CVD incidence.

Most studies providing data on survival in patients with atherosclerosis only address a single disease site: heart, brain or legs. Therefore, our objective was to determine risk of death after first hospital admission for atherosclerotic disease located at different sites. A nationwide cohort of patients hospitalized for the first time for acute myocardial infarction (AMI), peripheral arterial disease of the lower extremities (PAD) or ischemic stroke was identified through linkage of national registers. The mortality rate in AMI patients was compared to mortality rate in ischemic stroke and PAD patients by estimating relative risks (with 95%CI). Cox's proportional hazard models were used to estimate sex differences in risk of death. Case fatality was high for ischemic stroke patients (men:21.0%, women:23.8%) and AMI patients (men:12.7%, women:20.9%) though low for PAD patients (men:2.4%, women:3.5%). The five-year risk of death was similar for male AMI compared to PAD patients (men: RR1.04; 95%CI 0.98-1.11). The risk of death for ischemic stroke patients remained the highest though the differences with AMI and PAD patients attenuated. The dynamics of mortality over follow-up time clearly differ between atherosclerotic diseases, located at different vascular beds. The risk of death increases considerably over follow-up time for PAD patients, and 5 years after first hospital admission the differences in risks of death between AMI- and PAD patients and between AMI- and ischemic stroke patients have largely attenuated. Clinicians should be aware of these dynamics of mortality over follow-up time to provide optimal secondary prevention treatment.

Background In Europe, for primary prevention of cardiovascular diseases (CVD), the Systematic COronary Risk Evaluation (SCORE) risk charts for high-risk and low...