Cardiovascular risk communication strategies in primary prevention. A systematic review with narrative synthesis

Aim: To evaluate the effectiveness of cardiovascular risk communication strategies to improve understanding and promote risk factor modification. Design: Systematic review with narrative synthesis. Data sources: A comprehensive database search for quantitative and qualitative studies was conducted in five databases, Cumulative Index to Nursing and Allied health Literature (CINAHL), Medical Literature Analysis and Retrieval System Online (MEDLINE), EMBASE, Applied Social Sciences Index and Abstracts (ASSIA) and Web of Science. The searches were conducted between 1980 and July 2019. Review methods: The systematic review was conducted in accordance with Cochrane review methods. Data were extracted and a narrative synthesis of quantitative and qualitative results was undertaken. Results: The abstracts of 16,613 articles were assessed and 210 underwent in‐depth review, with 31 fulfilling the inclusion criteria. We observed significant heterogeneity across study designs and outcomes. Nine communication strategies were identified including numerical formats, graphical formats, qualitative information, infographics, avatars, game interactions, timeframes, genetic risk scores and cardiovascular imaging. Strategies that used cardiovascular imaging had the biggest impact on health behaviour change and risk factor modification. Improvements were seen in diet, exercise, smoking, risk scores, cholesterol and intentions to take preventive medication. Conclusion: A wide range of cardiovascular risk communication strategies has been evaluated, with those that employ personalized and visual evidence of current cardiovascular health status more likely to promote action to reduce risk. Impact: Future risk communication strategies should incorporate methods to provide individuals with evidence of their current cardiovascular health status

Implementation of a high sensitivity cardiac troponin i assay and risk of myocardial infarction or death at five years:Observational analysis of a stepped wedge, cluster randomised controlled trial

Abstract:Objective: To evaluate the impact of implementing a high sensitivity assay for cardiac troponin I on long term outcomes in patients with suspected acute coronary syndrome. Design: Secondary observational analysis of a stepped wedge, cluster randomised controlled trial. Setting: 10 secondary and tertiary care centres in Scotland, UK. Participants: 48 282 consecutive patients with suspected acute coronary syndrome. Myocardial injury was defined as any high sensitivity assay result for cardiac troponin I &gt;99th centile of 16 ng/L in women and 34 ng/L in men. Intervention: Hospital sites were randomly allocated to either early (n=5 hospitals) or late (n=5 hospitals) implementation of a high sensitivity cardiac troponin I assay with sex specific diagnostic thresholds. Main outcome measure: The main outcome was myocardial infarction or death at five years. Results: 10 360 patients had cardiac troponin concentrations greater than the 99th centile, of whom 1771 (17.1%) were reclassified by the high sensitivity assay. The five year incidence of subsequent myocardial infarction or death before and after implementation of the high sensitivity assay was 29.4% (5588/18 978) v 25.9% (7591/29 304), respectively, in all patients (adjusted hazard ratio 0.97, 95% confidence interval 0.93 to 1.01), and 63.0% (456/720) v 53.9% (567/1051), respectively, in those reclassified by the high sensitivity assay (0.82, 0.72 to 0.94). After implementation of the high sensitivity assay, a reduction in subsequent myocardial infarction or death was observed in patients with non-ischaemic myocardial injury (0.83, 0.75 to 0.91) but not in those with type 1 or type 2 myocardial infarction (0.92, 0.83 to 1.01 and 0.98, 0.84 to 1.14). Conclusions: Implementation of a high sensitivity cardiac troponin I assay in the assessment of patients with suspected acute coronary syndrome was associated with a reduced risk of subsequent myocardial infarction or death at five years in those reclassified by the high sensitivity assay. Improvements in outcome were greatest in patients with non-ischaemic myocardial injury, suggesting a broader benefit beyond the identification of myocardial infarction. Trial registration: ClinicalTrials.gov NCT01852123.</p

Uniform or Sex-Specific Cardiac Troponin Thresholds to Rule-out Myocardial Infarction at Presentation

Background: Myocardial infarction can be ruled out in patients with a single cardiac troponin measurement. Whether use of a uniform rule-out threshold has resulted in sex-differences in care remains unclear.Objectives: To evaluate implementation of a uniform rule-out threshold in females and males with possible myocardial infarction, and to derive and validate sex-specific thresholds. Methods: The implementation of a uniform rule-out threshold (&lt;5 ng/L) with a high-sensitivity cardiac troponin I assay was evaluated in consecutive patients presenting with possible myocardial infarction. The proportion of low-risk patients discharged from Emergency Department (ED) and incidence of myocardial infarction or cardiac death at 30 days were determined. Sex-specific thresholds were derived and validated, and proportion of female and male patients stratified as low-risk compared with uniform threshold.Results: In 16,792 patients (58±17 years, 46% female) care was guided using a uniform threshold. This identified more female than male patients as low-risk (73% versus 62%), but a similar proportion of low-risk patients were discharged from ED (81% for both) with fewer than 5 (&lt;0.1%) patients having a subsequent myocardial infarction or cardiac death at 30 days. Compared to uniform threshold of &lt;5 ng/L, use of sex-specific thresholds would increase the proportion of female (61.8% versus 65.9%) and reduce the proportion of male (54.8% versus 47.8%) patients identified as low-risk.Conclusions: Implementation of a uniform rule-out threshold for myocardial infarction was safe and effective in both sexes. Sex-specific rule-out thresholds should be considered, but their impact on effectiveness and safety may be limited.Keywords: Cardiac troponin, sex, myocardial infarction<br/