Aims There is debate about the optimum algorithm for cardiovascular disease (CVD) risk estimation. We conducted head-to-head comparisons of four algorithms recommended by primary prevention guidelines, before and after “re-calibration”, a method that adapts risk algorithms to take account of differences in the risk characteristics of the populations being studied. Methods and Results Using individual-participant data on 360,737 participants without CVD at baseline in 86 prospective studies from 22 countries, we compared the Framingham Risk Score (FRS), Systematic Coronary Risk Evaluation (SCORE), Pooled Cohort Equations (PCE), and Reynolds Risk Score (RRS). We calculated measures of risk discrimination and calibration, and modelled clinical implications of initiating statin therapy in people judged to be at “high” 10-year CVD risk. Original risk algorithms were re-calibrated using the risk factor profile and CVD incidence of target populations. The four algorithms had similar risk discrimination. Before re-calibration, FRS, SCORE and PCE over-predicted CVD risk on average by 10%, 52%, and 41%, respectively, while RRS under-predicted by 10%. Original versions of algorithms classified 29-39% of individuals aged ≥40 years as high-risk. By contrast, re-calibration reduced this proportion to 22-24% for every algorithm. We estimated that to prevent one CVD event, it would be necessary to initiate statin therapy in 44-51 such individuals using original algorithms, in contrast to 37-39 individuals with re-calibrated algorithms. Conclusion Before re-calibration, the clinical performance of four widely used CVD risk algorithms varied substantially. By contrast, simple re-calibration nearly equalised their performance and improved modelled targeting of preventive action to clinical need.
Based on this European population study, ACC/AHA and ESC prevention guidelines often did not align at the individual level. However, for one-fifth of the general population, guidelines on both sides of the Atlantic recommend statin initiation, with trial data supporting the efficacy. There should be no controversy about providing optimal preventive medication to these individuals.
BackgroundThe purpose of this study was to determine how American College of Cardiology/American Heart Association (ACC/AHA) 2013 and European Society of Cardiology 2016 guidelines for the primary prevention of atherosclerotic cardiovascular disease (CVD) compare in reflecting the totality of accrued randomised clinical trial evidence for statin treatment at population level.MethodsFrom 1997–2008, 7279 participants aged 45–75 years, free of atherosclerotic cardiovascular disease, from the population-based Rotterdam Study were included. For each participant, we compared eligibility for each one of 11 randomised clinical trials on statin use in primary prevention of CVD, with recommendations on lipid-lowering therapy from the ACC/AHA and European Society of Cardiology (ESC) guidelines. Atherosclerotic cardiovascular disease incidence and cardiovascular disease mortality rates were calculated.ResultsThe proportion of participants eligible for each trial ranged from 0.4% for ALLHAT-LLT to 30.8% for MEGA. The likelihood of being recommended for lipid-lowering treatment was lowest for those eligible for low-to-intermediate risk RCTs (HOPE-3, MEGA, and JUPITER), and highest for high-risk individuals with diabetes (MRC/BHF HPS, CARDS, and ASPEN) or elderly PROSPER. Eligibility for an increasing number of randomised clinical trials correlated with a greater likelihood of being recommended lipid-lowering treatment by either guideline (p < 0.001 for both guidelines).ConclusionCompared to RCTs done in high risk populations, randomised clinical trials targeting low-to-intermediate risk populations are less well-reflected in the ACC/AHA, and even less so in the ESC guideline recommendations. Importantly, the low-to-intermediate risk population targeted by HOPE-3, the most recent randomised clinical trial in this field, is not well-captured by the current European prevention guidelines and should be specifically considered in future iterations of the guidelines.
Summary Introduction Numerous challenges and barriers have emerged since changing the minimum requirement for those interested in pursuing employment as a nurse in Europe to a baccalaureate degree. To analyze the perceptions of baccalaureate nurses regarding the current status of their profession and the issues involved in implementing the prerequisite of earning a baccalaureate degree in order to practice as nurses in Bosnia and Herzegovina. Methods A series of six focus groups were undertaken with 49 baccalaureate nurses employed in primary health care centers and regional hospitals. The focus groups were recorded and transcribed verbatim. Data collected were analyzed using conventional content analysis approach. Results Baccalaureate nurses report dissatisfaction with their level of autonomy and anxiety over their limited career opportunities. They expressed concern over difficult working conditions, inadequate financial compensation, and ongoing resistance by physicians as the primary barriers to implementing advanced nursing education and professional reform. The global image of the nursing profession is negative. Conclusion The perception is that revising the legal framework regarding nursing qualifications, duties, and standards will result in reform necessary to positively affect the during profession. Progress toward implementing reform of the nursing profession is negligible. Addressing barriers such as work environment, lack of job classification, fair payment, autonomy, and interdisciplinary collaboration toward the competences of baccalaureate nurse is essential if successful reform is to occur.
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