SMART risk factor screening in patients at high vascular risk

Abstract

Studies presented in this thesis focused on the relationship between the presence of coronary heart disease and intra-abdominal fat, and the relationship between leisure-time physical activity and the presence of metabolic syndrome, incidence of type 2 diabetes and recurrence of vascular events in high-risk patients. In addition, two risk factor management strategies in patients with clinical manifest vascular disease were evaluated. We demonstrated that waist circumference had the strongest association with coronary heart disease in patients with peripheral arterial disease. It has been shown that physical activity can influence insulin sensitivity and metabolic syndrome independent of weight loss. We demonstrated that the prevalence of metabolic syndrome and insulin resistance was markedly lower in physically active patients than in physically inactive patients, independent of body weight. Furthermore, we found that physically inactive patients had a higher incidence of type 2 diabetes than physically active patients. Moreover, the combined effect of physical inactivity and obesity poses an even greater risk for the development of type 2 diabetes than either condition alone. We showed also that patients who were moderately and vigorously physically active had a lower risk of a recurrent vascular event and all-cause mortality. The risk of ischemic stroke, carotid interventions, and lower-limb vascular interventions was lower in physically active patients than in inactive patients. Thus, physical activity is associated with a lower risk of the presence of metabolic syndrome, insulin resistance, type 2 diabetes, non-fatal and fatal vascular events and all-cause mortality in patients with manifest arterial disease. The other part of this thesis concerns new strategies aiming at better risk factor-management in order to prevent progression of atherosclerosis. A multidisciplinary vascular screening program with an additional letter to the treating specialist with medical treatment recommendations in case of new or poorly controlled risk factors (intervention group) resulted in a lower systolic blood pressure and LDL-cholesterol compared with usual care alone (reference group) in patients with manifest arterial disease or type 2 diabetes. Moreover, patients in the intervention group reached the treatment goal for LDL-cholesterol more often than patients in the reference group. This study showed that systematic screening for risk factors contributed to a slightly better reduction of risk factors in patients with established vascular disease or type 2 diabetes. However, a large proportion of the patients did not reach the treatment goals according to (inter)national treatment guidelines. Thus, systematic screening alone, without adequate monitoring of vascular risk factors, is not enough for risk factor management in high-risk patients. The another strategy showed that a written risk factor treatment agreement between general practitioner and hospital for vascular risk factors achieved the treatment goals for total cholesterol and LDL-cholesterol significantly more often than usual care alone. This study revealed that a written agreement on risk factor treatment between general practitioner and hospital for individual patients, in whom vascular risk factors have been screened, resulted in slightly better management of vascular risk factors in patients with manifest arterial diseases.