- Research article
- Open Access
- Open Peer Review
Low use of statins for secondary prevention in primary care: a survey in a northern Swedish population
© The Author(s). 2016
- Received: 5 February 2016
- Accepted: 28 July 2016
- Published: 11 August 2016
Cholesterol-lowering therapy with statins is recommended in established cardiovascular disease (CVD) and should be considered for patients at high cardiovascular risk. We surveyed statin treatment before first-time myocardial infarction in clinical practice compared to current guidelines, in patients with and without known CVD in primary care clinics with general practitioners (GPs) on short-term contracts vs. permanent staff GPs.
A total of 931 patients (345 women) in northern Sweden were enrolled in the study between November 2009 and December 2014 and stratified by prior CVD, comprising angina pectoris, revascularisation, ischaemic stroke or transitory ischaemic attack, or peripheral artery disease. Primary care clinics were classified by the proportion of GP salaries that were paid to GPs working on short-term contracts: low (0–9 %), medium (10–39 %), or high (≥40 %). We used logistic regression to identify determinants of statin treatment.
Among patients with prior CVD, only 34.5 % received statin treatment before myocardial infarction. The probability of statin treatment decreased with age (≥70 years OR 0.30; 95 % CI 0.13–0.66) and female gender (OR 0.39; 95 % CI 0.20–0.78) but increased in patients with diabetes (OR 3.52; 95 % CI 1.75–7.08). Among patients with prior CVD, the type of primary care clinic was not predictive of statin treatment. In the entire study cohort, 17.3 % of patients were treated with statins; women < 70 years old were more likely to receive statin treatment than women ≥70 years old (OR 3.24; 95 % CI 1.64–6.38), and men ≥70 years old were twice as likely to be treated with statins than women of the same age (OR 2.22; 95 % CI 1.31–3.76) after adjusting for diabetes and CVD. Overall, patients from clinics with predominantly permanent staff GPs received statin therapy less frequently than those with GPs on short-term contracts.
In patients with prior CVD we found considerable under-treatment with statins, especially among women and the elderly. Methodologies for case findings, recall, and follow-up need to be improved and implemented to reach the goals for CVD prevention in clinical practice.
- Cardiovascular disease
- Myocardial infarction
- Secondary prevention
Statin treatment reduces cardiovascular (CV) morbidity and mortality in patients at increased risk of CV events [1–5]. The Scandinavian simvastatin survival study group (4S) was the first to report decreased CV mortality from statin treatment . Several different statins have since become available at low cost as generic drugs. The pharmacological mechanism common to all statins is inhibition of the rate controlling enzyme Hydroxymethylglutaryl-CoA reductase in cholesterol synthesis , whereas the relative efficiency depends on the dose and type of statin . The most commonly reported adverse effects related to statins are muscle symptoms, and asymptomatic liver enzyme elevation [8–12]. The risk of incident diabetes is slightly increased by statins, but it is outweighed by the total CV risk reduction in treated patients [9, 13, 14].
Treatment of patients with previous cardiovascular disease (CVD) (i.e., secondary prevention) targets patients at very high CV risk, in contrast to treatment of persons apparently free from disease (i.e., primary prevention) . Other patients with a very high or high total CV risk are those with diabetes (type 2 diabetes or type 1 diabetics with microalbuminuria), chronic kidney disease, or very high levels of individual risk factors [15, 16]. Statin treatment should be offered to women with the same therapeutic targets as men [1, 15, 17, 18]. Previous trials have had positive results with statin therapy among elderly patients [1, 19, 20]. In patients with established CVD, and there is evidence of the same relative risk reduction up to 75–80 years of age [21, 22].
A scoring algorithm can be used to estimate CV risk in patients without previously diagnosed CVD, e.g. The Swedish SCORE chart for cardiovascular risk (10-year risk of CV death is calculated from age, sex, smoking status, systolic blood pressure, and total serum cholesterol) , and several algorithms have been put forth [24–27]. The restriction of SCORE to ages 40–65 years is a problem because patients over 65 years of age are also eligible for preventive drug treatment. A SCORE value ≥5 % is proposed to be the cut-off for defining patients at high CV risk who could benefit from lipid-lowering drug treatment [28, 29].
To identify patients at increased risk of CVD, the participation of general practitioners (GPs) is crucial , but the implementation of treatment guidelines in practice may still be insufficient. Inadequate knowledge, time constraints, and insufficient patient compliance are barriers to implementing guidelines on CVD prevention [30–32]. Concerns have also been raised regarding overestimating risk and the consequences of overusing pharmacotherapy in national populations [33–35].
Lower adherence to therapy is associated with the patient’s understanding of risk in relation to disease , the provider-patient relationship, and continuity of care . However, before barriers to implementation of risk-adjusted prevention in primary care can be dealt with, they must be identified [34, 35, 38–40]. What still remains to bridge, is the gap between clinical practice and the optimal treatment with statins according to scientific evidence. Therefore, we designed a population-based survey of patients hospitalised with first-time myocardial infarction (MI). The primary aim of this study was to assess treatment with statins prior to first-time MI, in patients with and without previously diagnosed CVD. Another aim was to assess treatment differences related to primary care clinics’ use of GPs on short- term contracts.
Setting and participants
We conducted a population-based survey in the region of Jämtland Härjedalen, northern Sweden, which has one central cardiology unit and 21 primary care clinics run by the regional health authorities. Roughly half of the patients live in rural communities, with primary care clinics available in each. Participating patients were hospitalised with first-time MI type 1 according to the universal definition [41, 42] between November 26, 2009, and December 31, 2014. The patients were identified from a population-based secondary prevention study after acute coronary syndrome (ACS), “The Nurse-Based Age Independent Intervention to Limit Evolution of Disease After Acute Coronary Syndrome (NAILED ACS) Risk Factor Trial”; the outline of this study was published previously . Baseline medical data and demographics were recorded during the initial hospitalisation by experienced nursing staff. The patients were stratified by prior CVD, which comprised angina pectoris, revascularisation (coronary artery bypass grafting or percutaneous coronary intervention), ischaemic stroke or transitory ischaemic attack (TIA), or peripheral artery disease (PAD). PAD comprised leg artery disease, a stenosing lesion of the carotid, or atherosclerotic aneurysm. The 10-year risk of fatal CV events was manually estimated from the pre-existing baseline data for patients 40–65 years of age at study entry without prior CVD or diabetes, according to the Swedish SCORE chart in use during the study period . The primary care clinics within the study area were classified according to the percent of salaries allocated to GPs working on short-term contracts vs. salaries paid to GPs on the permanent staff between 2010 and 2014. This data was provided by the regional health authorities.
Patient characteristics are presented as proportions or means. We used the chi-squared test or Fisher’s exact test, as appropriate, to compare proportions and the two-sided Student’s t-test to compare means. In a trend analysis, age was stratified in 10-year intervals. In the regression model, age was dichotomised at 70 years, the mean age of the study population. Primary care clinics were stratified into three levels according to the primary care clinics’ use of GPs on short-term contracts, with approximately one-third of study patients in each level: low (0–9 %), medium (10–39 %), and high (≥40 %) short-term clinics. We used univariate logistic regression with patients stratified by prior CVD to identify patient determinants that were predictive of statin treatment. In a multivariable logistic model, we included the interaction term “age ≥70 years × female gender” with age ≥70 years, female gender, diabetes, and prior CVD as covariates. The SCORE variable was not included in the regression model due to bidirectional causality between statin treatment and the subsequent SCORE value. In an interaction model of age and gender, we calculated ORs for statin treatment adjusted for diabetes and prior CVD. The level of significance was set at p < 0.05. Sample size calculations were performed using WINPEPI, version 11.54 , and all other statistical analyses were performed in IBM SPSS version 22.
The study included 931 patients (345 women) with a first-time MI. The mean patient age was 74.7 years in women and 68.2 years in men. Most study patients (60.5 %) were current or previous manual workers. A complete background of the study population was described elsewhere .
Characteristics of patients admitted for first-time myocardial infarction
Total n = 931
Prior CVD n = 166 (17.8 %)
No prior CVD n = 765 (82.2 %)
Age at admission to hospital, mean (SD)
345 (37.1 %)
71/166 (42.8 %)
274/765 (35.8 %)
531 (60.5 %)
96/151 (63.6 %)
435/727 (59.8 %)
198 (21.7 %)
21/159 (13.2 %)
177/755 (23.4 %)
Systolic blood pressure, mmHg, mean (SD) (67 missing)a
Diastolic blood pressure, mmHg, mean (SD) (67 missing)a
Total cholesterol, mmol/L, mean (SD) (44 missing)
LDL cholesterol, mmol/L, mean (SD) (56 missing)
ST-elevation myocardial infarction
321 (34.5 %)
36/166 (21.7 %)
285/765 (37.3 %)
Past medical history
38 (4.1 %)
38/166 (22.9 %)
Ischaemic stroke or TIA
52 (5.6 %)
52/166 (31.3 %)
Angina pectoris, current diagnosis
109 (11.7 %)
109/166 (65.7 %)
Peripheral artery disease (PAD)
19 (2.0 %)
19/166 (11.4 %)
Hypertension, current diagnosis
511 (54.9 %)
124/166 (74.7 %)
387/765 (50.6 %)
Diabetes, current diagnosis
172 (18.5 %)
49/166 (29.5 %)
123/765 (16.1 %)
Medication at admission to hospital
292 (31.5 %)
69/165 (41.8 %)
223/763 (29.2 %)
265 (28.6 %)
89/165 (53.9 %)
176/762 (23.1 %)
Calcium channel blockers
207 (22.4 %)
60/164 (36.6 %)
147/762 (19.3 %)
248 (26.8 %)
72/165 (43.6 %)
176/762 (23.1 %)
49 (5.3 %)
45/165 (27.3 %)
4/763 (0.5 %)
161 (17.3 %)
57/165 (34.5 %)
104/763 (13.6 %)
222 (23.9 %)
112/165 (67.9 %)
110/763 (14.4 %)
Primary care clinics by proportion of GP salaries paid to GPs working on short-term contracts
Proportion of GP salaries paid to GPs working on short-term contracts
Number of primary care clinics
Number of patients (%)
Low (0–9 %)
353 (38 %)
Medium (10–39 %)
333 (36 %)
High (≥40 %)
245 (26 %)
931 (100 %)
Statin treatment prior to first-time myocardial infarction according to patient and primary care clinic characteristics (n = 928)
Treatment with statins
57/344 (16.6 %)
104/584 (17.8 %)
Age <70 years
67/433 (15.5 %)
Age ≥70 years
94/495 (19.0 %)
95/528 (18.0 %)
Non-manual employees and self-employed
58/347 (16.7 %)
Prior cardiovascular disease (CVD)
57/165 (34.5 %)
No prior CVD
104/763 (13.6 %)
Diabetes, current diagnosis
84/171 (49.1 %)
Diabetes not recorded
77/757 (10.2 %)
SCORE <5 %
11/144 (7.6 %)
SCORE ≥5 % - <10 %
3/55 (5.5 %)
SCORE ≥10 %
0/15 (0.0 %)
Proportion of GP salaries paid to GPs working on short-term contracts
0–9 % (low short-term clinics)
48/351 (13.7 %)
10–39 % (medium)
54/255 (21.2 %)
≥ 40 % (high)
59/322 (18.3 %)
Patients with prior CVD
Statin treatment prior to first-time myocardial infarction according to age (n = 928)
Age at hospital admission, years
Prior CVD (n = 165)
No prior CVD (n = 763)
1/1 (100 %)
4/45 (8.9 %)
2/4 (50 %)
13/117 (11.1 %)
15/26 (57.7 %)
32/240 (13.3 %)
20/53 (37.7 %)
36/204 (17.6 %)
18/66 (27.3 %)
17/126 (13.5 %)
1/15 (6.7 %)
2/31 (6.5 %)
57/165 (34.5 %)
104/763 (13.6 %)
Crude odds ratios (ORs) for statin treatment before first-time myocardial infarction stratified by cardiovascular disease (CVD) (n = 928)
Prior CVD n = 165
No prior CVD n = 763
OR (95 % CI)
OR (95 % CI)
Age ≥70 years at admission to hospital
Proportion of GP salaries paid to GPs working on short-term contracts
0–9 % short-term
10–39 % short-term vs. 0–9 %
≥ 40 % to short-term vs. 0–9 %
Analyses including the entire patient cohort: Statin treatment by gender and age
Adjusted odds ratios (ORs) for statin treatment prior to first-time myocardial infarction (n = 928)
Adjusted OR (95 % CI)
Age ≥70 years
Age ≥70 years × female gender
Prior cardiovascular disease (CVD)
Adjusted odds ratios (ORs) for statin treatment by age and gender (n = 928)
Age at admission for first-time myocardial infarction
<70 years OR (95 % CI)
≥70 years OR (95 % CI)
1.72 (0.99–2.99) (n = 326)
2.22 (1.31–3.76) (n = 258)
3.24 (1.64–6.38) (n = 107)
1.00 (n = 237)
Only one-third of patients with a first-time MI and previously diagnosed CVD were being treated with statins before the MI, despite guidelines that support active treatment of patients with known CVD [15, 29, 45]. In prior CVD patients, increasing age and female gender were associated with a lower probability of statin treatment, whereas diabetes was associated with a higher probability of statin treatment.
Our results revealed barriers to statin treatment for secondary prevention. The mean LDL cholesterol levels (3.0 mmol/L) exceeded the target level for high-risk patients according to the former and present European guidelines for CVD prevention in clinical practice [29, 46]. The Swedish guidelines for treatment of CVD during the study period recommended a target LDL cholesterol level <2.5 mmol/L in patients at very high CV risk .
Reasons for the underuse of statin treatment may be several: a lack of secondary prevention programmes; patients’ diminishing adherence to therapy over time; experienced or expected side effects of statins; and insufficient adherence to clinical guidelines among physicians.
The quality of CV risk management is associated with routines for case finding, patient follow-up, and CVD risk assessment integrated into the electronic medical record system . Follow-up programmes delivered in primary care or as a nurse-based telephone follow-up have shown promising results with improved CV risk factors and treatment for coronary disease [43, 49–51].
Adherence to medication is associated with the access to and continuity of healthcare . Within our study area, the continuity of primary care was impaired due to lack of GPs working as permanent staff. However, fewer patients received statin treatment at primary care clinics with predominantly permanent staff GPs, for unknown reasons.
The initial CVD event among our study patients may have occurred several years before the first-time MI. A 2-year adherence to statin therapy of 36.1 % for chronic coronary disease has been reported among elderly patients, and it is even less for primary prevention .
Concerns about side effects is associated with low adherence to drug therapy [53, 54]. Consequently, discontinuation of statins within 6 months after initiating therapy has been attributed to negative statin-related news reports in public media .
Discontinuation of previously initiated statin therapy due to side effects or negative public media reporting may have contributed considerably to the low number of patients receiving statins for secondary prevention. Follow-up of patients remains essential, even in patients with symptoms attributable to drug treatment, as most patients that are rechallenged with a statin are still able to tolerate statins long-term .
The usage of clinical guidelines in clinical practice is known to be incomplete [30, 57, 58], and the adoption of new treatment targets may be a slow process in general practice [35, 38, 39]. Patients’ understanding of the CV risk concept may also be an important barrier for preventive treatment .
Because we recruited patients of all ages, comparisons to population-based cohorts from restricted age segments should be made with caution. According to the “Irish Longitudinal Study on Ageing” , the proportion of patients undergoing statin treatment was 68.8 % for patients with known CVD, 57.4 % for diabetic patients, and 19.7 % when SCORE of risk was ≥5 %. Statin treatment in 49.1 % of our diabetic patients was possibly related to a twice yearly follow-up programme for diabetics. The modest rate of statin treatment in patients with prior CVD (34.5 %) may have been related to a lack of follow-up for CVD patients in our study area.
Women ≥70 years of age were less frequently on current statin treatment than men in the same age group or younger women possibly due to combinations of several causes. Female gender and age (>80 years) are independent risk factors for statin-associated muscle symptoms [12, 60]. A possible interaction between age and gender in relation to discontinuation of statin therapy should be researched further.
Awareness of personal CV risk profiles may be important for adherence to medication. In a recent survey conducted in women, underestimation of CV risk was common, with age as the most significant predictor . In our cohort, only 3/70 patients with a SCORE ≥5 % for CV risk received statin treatment. Apparently, CV risk assessment by the SCORE chart was not implemented in clinical practice during the study period.
The reasons for the lower proportion of overall statin treatment among patients from primary care clinics with more permanent staff GPs (low short-term clinics) are not clear based on the study data. To provide more supporting evidence concerning the prescription preferences of GPs at different experience levels, a qualitative study approach could have been applied, but it was beyond the scope of our present study.
The gap between CVD guidelines and clinical practice has been reported previously [62, 63], but the age- and gender-related aspects of this gap has not gained sufficient attention. To bridge this gap it is necessary to develop and implement procedures for case finding, recall, and follow-up of patients with established CVD [64, 65]. Such procedures should be integrated into electronic medical records as much as possible. Algorithms for CV risk assessment should be fully implemented in clinical practice, since single risk factor assessment could lead to false conclusions of CV risk, with potential overuse of drugs.
We enrolled MI patients admitted to the hospital; therefore, our results are not fully comparable to findings in community-based cohorts. Data on the time of the initiation of statin treatment, discontinuation of treatment, and side effects were not available. In most patients, angina pectoris, one of the components of the CVD diagnosis, was determined as a clinical diagnosis and not evaluated by coronary angiography. In medical practice, treatment decisions are often based on clinical risk evaluation, and invasive procedures are not always required or justified [66, 67]. In patients aged 40–65 years, the SCORE of CV risk  was determined from baseline data a posteriori. Due to a bidirectional relationship between statin therapy and the SCORE value, in patients achieving lower cholesterol levels after initiation of statins, the SCORE variable was not included in the regression model of determinants of statin treatment. Pre-treatment cholesterol levels were not available.
A post hoc calculation of sample sizes required to detect a difference in statin treatment with respect to primary care clinics’ use of short-term GPs, stratified by prior CVD, revealed a need for a larger sample size to reach a power of 0.8 at a significance level of 0.05. Thus, the study had insufficient power to detect a between-clinic difference in the use of statins after stratification by prior CVD.
We compared primary care clinics by the use of GPs working on short-term contracts vs. permanent staff GPs as a substitute for a measurement on the provider-patient level. Direct measurement at the level of care was not possible to obtain within the resources of this study.
Non-surviving patients due to out-of-hospital cardiac arrest were not included in the study, which limits the results to being applied to patients alive after a first-time MI.
In patients with prior CVD we found considerable under-treatment with statins, especially among women and the elderly. In the entire study cohort, women ≥70 years of age had lower probability of statin treatment than men of the same age or younger women, after adjusting for diabetes and prior CVD. Overall, patients from clinics with predominantly permanent staff GPs received statin therapy less frequently than those with GPs on short-term contracts. Methodologies for case finding, recall, and follow-up of CVD patients need to be improved and implemented to achieve the goals for CVD prevention in clinical practice.
ACE, angiotensin-converting-enzyme; ACS, acute coronary syndrome; ARB, angiotensin-receptor blocker; CABG, coronary artery bypass grafting; CV, cardiovascular; CVD, cardiovascular disease; DDD, defined daily dose; GP, general practitioner; LDL, low density lipoprotein; MI, myocardial infarction; NAILED ACS, The Nurse-Based Age Independent Intervention to Limit Evolution of Disease After Acute Coronary Syndrome Risk Factor Trial; PAD, peripheral artery disease; PCI, percutaneous coronary intervention; RCT, randomised placebo-controlled trial; SCORE, systematic coronary risk intervention; TIA, transitory ischaemic attack.
The authors wish to express their sincere gratitude to all study participants and the staff engaged in the Nailed ACS Risk Factor Trial.
This study was supported by grants from the Swedish Region of Jämtland Härjedalen.
Availability of data and materials
Patient level data will be available on request, provided an approval from the Regional Ethical Review Board of Umeå University, Sweden.
GN conceived the study, performed the statistical analyses, and drafted the manuscript. TM was in charge of baseline data provided from the Nailed ACS trial, supervised the study design, participated in data analysis, and helped draft the manuscript. ES supervised the study design, participated in data analysis, and helped draft the manuscript. LS gave advice on the statistical analyses, participated in data analysis, and helped draft the manuscript. All authors read and approved the final manuscript.
GN: GP, doctoral student, Department of Public Health and Clinical Medicine, Unit of Research, Education and Development - Östersund, Umeå University, Sweden.
ES: GP, Associate Professor, Family Medicine, Department of Public Health and Clinical Medicine, Umeå University, Sweden.
LS: Master of Science, Unit of Research, Education and Development - Östersund Hospital, Östersund, Sweden.
TM: Consultant in cardiology, Östersund Hospital, Associate Professor of Medicine, Department of Public Health and Clinical Medicine, Umeå University, Sweden.
The authors declare that they have no competing interests. The funders had no role in the study design, data collection, data analysis, or in writing the report.
Consent for publication
Ethics approval and consent to participate
Use of baseline data collected in the secondary preventive trial (NAILED ACS) was approved by the Regional Ethical Review Board of Umeå University (reference number 2013-204-32 M). Informed consent was provided by patients randomized in the NAILED ACS trial.
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- Baigent C, Blackwell L, Emberson J, Holland LE, Reith C, Bhala N, et al. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170,000 participants in 26 randomised trials. Lancet. 2010;376(9753):1670–81.View ArticlePubMedGoogle Scholar
- Baigent C, Keech A, Kearney PM, Blackwell L, Buck G, Pollicino C, et al. Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins. Lancet. 2005;366(9493):1267–78.View ArticlePubMedGoogle Scholar
- Mihaylova B, Emberson J, Blackwell L, Keech A, Simes J, Barnes EH, et al. The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials. Lancet. 2012;380(9841):581–90.View ArticlePubMedGoogle Scholar
- Taylor F, Huffman MD, Macedo AF, Moore TH, Burke M, Davey Smith G, et al. Statins for the primary prevention of cardiovascular disease. Cochrane database syst rev. 2013;1:Cd004816.Google Scholar
- TSSSS Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet. 1994;344(8934):1383–9.Google Scholar
- Istvan ES, Deisenhofer J. Structural mechanism for statin inhibition of HMG-CoA reductase. Science. 2001;292(5519):1160–4.View ArticlePubMedGoogle Scholar
- Weng TC, Yang YH, Lin SJ, Tai SH. A systematic review and meta-analysis on the therapeutic equivalence of statins. J Clin Pharm Ther. 2010;35(2):139–51.View ArticlePubMedGoogle Scholar
- Bruckert E, Hayem G, Dejager S, Yau C, Begaud B. Mild to moderate muscular symptoms with high-dosage statin therapy in hyperlipidemic patients--the PRIMO study. Cardiovasc Drugs Ther. 2005;19(6):403–14.View ArticlePubMedGoogle Scholar
- Finegold JA, Manisty CH, Goldacre B, Barron AJ, Francis DP. What proportion of symptomatic side effects in patients taking statins are genuinely caused by the drug? Systematic review of randomized placebo-controlled trials to aid individual patient choice. Eur J Prev Cardiol. 2014;21(4):464–74.View ArticlePubMedGoogle Scholar
- Law M, Rudnicka AR. Statin safety: a systematic review. Am J Cardiol. 2006;97(8a):52c–60c.View ArticlePubMedGoogle Scholar
- Naci H, Brugts J, Ades T. Comparative tolerability and harms of individual statins: a study-level network meta-analysis of 246 955 participants from 135 randomized, controlled trials. Circ Cardiovasc Qual Outcomes. 2013;6(4):390–9.View ArticlePubMedGoogle Scholar
- Stroes ES, Thompson PD, Corsini A, Vladutiu GD, Raal FJ, Ray KK, et al. Statin-associated muscle symptoms: impact on statin therapy-European Atherosclerosis Society Consensus Panel Statement on Assessment, Aetiology and Management. Eur Heart J. 2015;36(17):1012–22.View ArticlePubMedPubMed CentralGoogle Scholar
- Sattar N, Preiss D, Murray HM, Welsh P, Buckley BM, de Craen AJ, et al. Statins and risk of incident diabetes: a collaborative meta-analysis of randomised statin trials. Lancet. 2010;375(9716):735–42.View ArticlePubMedGoogle Scholar
- Waters DD, Ho JE, Boekholdt SM, DeMicco DA, Kastelein JJ, Messig M, et al. Cardiovascular event reduction versus new-onset diabetes during atorvastatin therapy: effect of baseline risk factors for diabetes. J Am Coll Cardiol. 2013;61(2):148–52.View ArticlePubMedGoogle Scholar
- Catapano AL, Reiner Z, De Backer G, Graham I, Taskinen MR, Wiklund O, et al. ESC/EAS Guidelines for the management of dyslipidaemias The Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS). Atherosclerosis. 2011;217(1):3–46.View ArticlePubMedGoogle Scholar
- Graham I, Atar D, Borch-Johnsen K, Boysen G, Burell G, Cifkova R, et al. European guidelines on cardiovascular disease prevention in clinical practice: full text. Fourth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts). Eur J Cardiovasc Prev Rehabil. 2007;14 Suppl 2:S1–113.View ArticlePubMedGoogle Scholar
- Brugts JJ, Yetgin T, Hoeks SE, Gotto AM, Shepherd J, Westendorp RG, et al. The benefits of statins in people without established cardiovascular disease but with cardiovascular risk factors: meta-analysis of randomised controlled trials. BMJ. 2009;338:b2376.View ArticlePubMedPubMed CentralGoogle Scholar
- Walsh JM, Pignone M. Drug treatment of hyperlipidemia in women. JAMA. 2004;291(18):2243–52.View ArticlePubMedGoogle Scholar
- TSSSS Group. Design and baseline results of the Scandinavian Simvastatin Survival Study of patients with stable angina and/or previous myocardial infarction. Am J Cardiol. 1993;71(5):393–400.View ArticleGoogle Scholar
- Lewis SJ, Moye LA, Sacks FM, Johnstone DE, Timmis G, Mitchell J, et al. Effect of pravastatin on cardiovascular events in older patients with myocardial infarction and cholesterol levels in the average range. Results of the Cholesterol and Recurrent Events (CARE) trial. Ann Intern Med. 1998;129(9):681–9.View ArticlePubMedGoogle Scholar
- Deedwania P, Stone PH, Bairey Merz CN, Cosin-Aguilar J, Koylan N, Luo D, et al. Effects of intensive versus moderate lipid-lowering therapy on myocardial ischemia in older patients with coronary heart disease: results of the Study Assessing Goals in the Elderly (SAGE). Circulation. 2007;115(6):700–7.View ArticlePubMedGoogle Scholar
- Shepherd J, Blauw GJ, Murphy MB, Bollen EL, Buckley BM, Cobbe SM, et al. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial. Lancet. 2002;360(9346):1623–30.View ArticlePubMedGoogle Scholar
- Wilhelmsen L, Wedel H, Conroy R, Fitzgerald T. The Swedish SCORE chart for cardiovascular risk. Better possibilities for prevention of cardiovascular diseases. Lakartidningen. 2004;101(20):1798–801.PubMedGoogle Scholar
- Conroy RM, Pyorala K, Fitzgerald AP, Sans S, Menotti A, De Backer G, et al. Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J. 2003;24(11):987–1003.View ArticlePubMedGoogle Scholar
- Cooney MT, Dudina A, D’Agostino R, Graham IM. Cardiovascular risk-estimation systems in primary prevention: do they differ? Do they make a difference? Can we see the future? Circulation. 2010;122(3):300–10.View ArticlePubMedGoogle Scholar
- Cooney MT, Dudina AL, Graham IM. Value and limitations of existing scores for the assessment of cardiovascular risk: a review for clinicians. J Am Coll Cardiol. 2009;54(14):1209–27.View ArticlePubMedGoogle Scholar
- D’Agostino Sr RB, Vasan RS, Pencina MJ, Wolf PA, Cobain M, Massaro JM, et al. General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation. 2008;117(6):743–53.View ArticlePubMedGoogle Scholar
- De Backer G, Ambrosioni E, Borch-Johnsen K, Brotons C, Cifkova R, Dallongeville J, et al. European guidelines on cardiovascular disease prevention in clinical practice. Third Joint Task Force of European and Other Societies on Cardiovascular Disease Prevention in Clinical Practice. Eur Heart J. 2003;24(17):1601–10.View ArticlePubMedGoogle Scholar
- Perk J, De Backer G, Gohlke H, Graham I, Reiner Z, Verschuren M, et al. European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts). Eur Heart J. 2012;33(13):1635–701.View ArticlePubMedGoogle Scholar
- Dallongeville J, Banegas JR, Tubach F, Guallar E, Borghi C, De Backer G, et al. Survey of physicians’ practices in the control of cardiovascular risk factors: the EURIKA study. Eur J Prev Cardiol. 2012;19(3):541–50.View ArticlePubMedGoogle Scholar
- Heidrich J, Behrens T, Raspe F, Keil U. Knowledge and perception of guidelines and secondary prevention of coronary heart disease among general practitioners and internists. Results from a physician survey in Germany. Eur J Cardiovasc Prev Rehabil. 2005;12(6):521–9.PubMedGoogle Scholar
- Hobbs FD, Erhardt L. Acceptance of guideline recommendations and perceived implementation of coronary heart disease prevention among primary care physicians in five European countries: the Reassessing European Attitudes about Cardiovascular Treatment (REACT) survey. Fam Pract. 2002;19(6):596–604.View ArticlePubMedGoogle Scholar
- Hartz I, Njolstad I, Eggen AE. Does implementation of the European guidelines based on the SCORE model double the number of Norwegian adults who need cardiovascular drugs for primary prevention? The Tromso study 2001. Eur Heart J. 2005;26(24):2673–80.View ArticlePubMedGoogle Scholar
- Marshall T. Estimating the value of information in strategies for identifying patients at high risk of cardiovascular disease. Inform Prim Care. 2006;14(2):85–92.PubMedGoogle Scholar
- van Steenkiste B, van der Weijden T, Stoffers HE, Grol R. Barriers to implementing cardiovascular risk tables in routine general practice. Scand J Prim Health Care. 2004;22(1):32–7.View ArticlePubMedGoogle Scholar
- van Steenkiste B, van der Weijden T, Timmermans D, Vaes J, Stoffers J, Grol R. Patients’ ideas, fears and expectations of their coronary risk: barriers for primary prevention. Patient Educ Couns. 2004;55(2):301–7.View ArticlePubMedGoogle Scholar
- Ho PM, Bryson CL, Rumsfeld JS. Medication adherence: its importance in cardiovascular outcomes. Circulation. 2009;119(23):3028–35.View ArticlePubMedGoogle Scholar
- Eichler K, Zoller M, Tschudi P, Steurer J. Barriers to apply cardiovascular prediction rules in primary care: a postal survey. BMC fam Pract. 2007;8:1.View ArticlePubMedPubMed CentralGoogle Scholar
- Sinclair G, Kerr A. The Bold Promise Project: a system change in primary care to support cardiovascular risk screening. N Z Med J. 2006;119(1245):U2312.PubMedGoogle Scholar
- Wells S, Furness S, Rafter N, Horn E, Whittaker R, Stewart A, et al. Integrated electronic decision support increases cardiovascular disease risk assessment four fold in routine primary care practice. Eur J Cardiovasc Prev Rehabil. 2008;15(2):173–8.View ArticlePubMedGoogle Scholar
- Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, et al. Third universal definition of myocardial infarction. Eur Heart J. 2012;33(20):2551–67.View ArticlePubMedGoogle Scholar
- Thygesen K, Alpert JS, White HD. Universal definition of myocardial infarction. Eur Heart J. 2007;28(20):2525–38.View ArticlePubMedGoogle Scholar
- Mooe T, Bjorklund F, Graipe A, Huber D, Jakobsson S, Kajermo U, et al. The Nurse-Based Age Independent Intervention to Limit Evolution of Disease After Acute Coronary Syndrome (NAILED ACS) Risk Factor Trial: Protocol for a Randomized Controlled Trial. JMIR Res Protoc. 2014;3(3):e42.View ArticlePubMedPubMed CentralGoogle Scholar
- Abramson JH. WINPEPI updated: computer programs for epidemiologists, and their teaching potential. Epidemiol Perspec Innov. 2011;8(1):1.View ArticleGoogle Scholar
- Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(25 Suppl 2):S1–45.View ArticlePubMedGoogle Scholar
- Graham I, Atar D, Borch-Johnsen K, Boysen G, Burell G, Cifkova R, et al. European guidelines on cardiovascular disease prevention in clinical practice: executive summary. Fourth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts). Eur J Cardiovasc Prev Rehabil. 2007;14 Suppl 2:E1–40.View ArticlePubMedGoogle Scholar
- Läkemedelsverket [Medical Products Agency] [www.lakemedelsverket.se]. Förebyggande av aterosklerotisk hjärt-kärlsjukdom. Vol. 3:2006: 16–31. Available from: https://lakemedelsverket.se/upload/om-lakemedelsverket/publikationer/information-fran-lakemedelsverket/Info_fr_LV_2006-3. Accessed 28 jan 2016.
- Ludt S, Campbell SM, Petek D, Rochon J, Szecsenyi J, van Lieshout J, et al. Which practice characteristics are associated with the quality of cardiovascular disease prevention in European primary care? Implement Sci. 2013;8:27.View ArticlePubMedPubMed CentralGoogle Scholar
- Bennett K, Jennings S, Collins C, Boland M, Leahy J, Bedford D, et al. Heartwatch: a secondary prevention programme in primary care in Ireland. Eur J Cardiovasc Prev Rehabil. 2008;15(6):651–6.View ArticlePubMedGoogle Scholar
- Fitzpatrick P, Fitz-Simon N, Lonergan M, Collins C, Daly L. Heartwatch: the effect of a primary care-delivered secondary prevention programme for cardiovascular disease on medication use and risk factor profiles. Eur J Cardiovasc Prev Rehabil. 2011;18(1):129–35.PubMedGoogle Scholar
- Jakobsson S, Irewall AL, Bjorklund F, Mooe T. Cardiovascular secondary prevention in high-risk patients: a randomized controlled trial sub-study. BMC Cardiovasc Disord. 2015;15(1):125.View ArticlePubMedPubMed CentralGoogle Scholar
- Jackevicius CA, Mamdani M, Tu JV. Adherence with statin therapy in elderly patients with and without acute coronary syndromes. JAMA. 2002;288(4):462–7.View ArticlePubMedGoogle Scholar
- Horne R, Chapman SC, Parham R, Freemantle N, Forbes A, Cooper V. Understanding patients’ adherence-related beliefs about medicines prescribed for long-term conditions: a meta-analytic review of the Necessity-Concerns Framework. PloS One. 2013;8(12):e80633.View ArticlePubMedPubMed CentralGoogle Scholar
- Grundy SM. Statin discontinuation and intolerance: the challenge of lifelong therapy. Ann Intern Med. 2013;158(7):562–3.View ArticlePubMedGoogle Scholar
- Nielsen SF, Nordestgaard BG. Negative statin-related news stories decrease statin persistence and increase myocardial infarction and cardiovascular mortality: a nationwide prospective cohort study. Eur Heart J. 2015. doi:10.1093/eurheart/ehv641.Google Scholar
- Zhang H, Plutzky J, Skentzos S, Morrison F, Mar P, Shubina M, et al. Discontinuation of statins in routine care settings: a cohort study. Ann Intern Med. 2013;158(7):526–34.View ArticlePubMedPubMed CentralGoogle Scholar
- Graham IM, Stewart M, Hertog MG. Factors impeding the implementation of cardiovascular prevention guidelines: findings from a survey conducted by the European Society of Cardiology. Eur J Cardiovasc Prev Rehabil. 2006;13(5):839–45.View ArticlePubMedGoogle Scholar
- Reiner Z, Sonicki Z, Tedeschi-Reiner E. Physicians’ perception, knowledge and awareness of cardiovascular risk factors and adherence to prevention guidelines: the PERCRO-DOC survey. Atherosclerosis. 2010;213(2):598–603.View ArticlePubMedGoogle Scholar
- Murphy C, Bennett K, Fahey T, Shelley E, Graham I, Kenny RA. Statin use in adults at high risk of cardiovascular disease mortality: cross-sectional analysis of baseline data from The Irish Longitudinal Study on Ageing (TILDA). BMJ Open. 2015;5(7):e008017.View ArticlePubMedPubMed CentralGoogle Scholar
- Ahmad Z. Statin intolerance. Am J Cardiol. 2014;113(10):1765–71.View ArticlePubMedGoogle Scholar
- Oertelt-Prigione S, Seeland U, Kendel F, Rucke M, Floel A, Gaissmaier W, et al. Cardiovascular risk factor distribution and subjective risk estimation in urban women--the BEFRI study: a randomized cross-sectional study. BMC Med. 2015;13:52.View ArticlePubMedPubMed CentralGoogle Scholar
- Cooney MT, Kotseva K, Dudina A, De Backer G, Wood D, Graham I. Determinants of risk factor control in subjects with coronary heart disease: a report from the EUROASPIRE III investigators. Eur J Prev Cardiol. 2013;20(4):686–91.View ArticlePubMedGoogle Scholar
- Kotseva K, Wood D, De Bacquer D, De Backer G, Ryden L, Jennings C, et al. EUROASPIRE IV: A European Society of Cardiology survey on the lifestyle, risk factor and therapeutic management of coronary patients from 24 European countries. Eur J Prev Cardiol. 2015. doi:10.1177/2047487315569401.Google Scholar
- Huber D, Henriksson R, Jakobsson S, Stenfors N, Mooe T. Implementation of a telephone-based secondary preventive intervention after acute coronary syndrome (ACS): participation rate, reasons for non-participation and 1-year survival. Trials. 2016;17(1):85.View ArticlePubMedPubMed CentralGoogle Scholar
- Jakobsson S, Huber D, Bjorklund F, Mooe T. Implementation of a new guideline in cardiovascular secondary preventive care: subanalysis of a randomized controlled trial. BMC Cardiovasc Disord. 2016;16(1):77.View ArticlePubMedPubMed CentralGoogle Scholar
- Pryor DB, Shaw L, Harrell Jr FE, Lee KL, Hlatky MA, Mark DB, et al. Estimating the likelihood of severe coronary artery disease. Am J Med. 1991;90(5):553–62.View ArticlePubMedGoogle Scholar
- Pryor DB, Shaw L, McCants CB, Lee KL, Mark DB, Harrell Jr FE, et al. Value of the history and physical in identifying patients at increased risk for coronary artery disease. Ann Intern Med. 1993;118(2):81–90.View ArticlePubMedGoogle Scholar