ObjectiveTo explore the association between health literacy and the risk of cardiovascular disease (CVD), and to assess the differential effects by health literacy level of a nurse-coordinated secondary prevention program (NCPP) in patients with coronary artery disease (CAD).MethodsData were collected in two medical centres participating in the RESPONSE trial (Randomised Evaluation of Secondary Prevention by Outpatient Nurse SpEcialists). CVD risk profiles were assessed at baseline and 12-month follow-up using the Systematic Coronary Risk Evaluation (SCORE). Health literacy was assessed by the short Rapid Estimate of Adult Literacy in Medicine (REALM-D) and the Newest Vital Sign (NVS-D); self-reported health literacy was evaluated by the Set of Brief Screening Questions (SBSQ-D).ResultsAmong 201 CAD patients, 18% exhibited reading difficulties, 52% had difficulty understanding and applying written information, and 5% scored low on self-reported health literacy. Patients with low NVS-D scores had a higher CVD risk [mean SCORE 5.2 (SD 4.8) versus 3.3 (SD 4.1), p < 0.01]. Nurse-coordinated care seemed to reduce CVD risk irrespective of health literacy levels without significant differences.ConclusionInadequate health literacy is prevalent in CAD patients in the Netherlands, and is associated with less favourable CVD risk profiles. Where many other forms of CVD prevention fail, nurse-coordinated care seems to be effective among patients with inadequate health literacy.

IntroductionDutch cardiovascular disease (CVD) prevention guidelines recommend the use of modified SCORE risk charts to estimate 10-year risk of fatal and nonfatal CVD (myocardial infarction, cerebrovascular disease and congestive heart failure). This combined risk is derived from the SCORE mortality risk using multipliers. These multipliers have been shown to underestimate overall CVD risk. We aimed to compare the current Dutch risk charts with charts that estimate a broader range of clinically relevant CVD using updated multipliers.MethodsWe constructed new risk charts for 10-year CVD using updated, recently published multipliers from the EPIC-Norfolk study, based on ratios of fatal CVD to clinically relevant CVD (fatal plus nonfatal CVD requiring hospitalisation for ischaemic heart disease, cardiac failure, cerebrovascular disease, peripheral artery disease, and aortic aneurysm). Our primary outcome was the proportion of the three risk categories, i. e. ‘high risk’ (>20% 10-year risk), ‘intermediate risk’ (10–19%) and ‘low risk’ (<10%) in the new risk charts as compared with the current risk charts.ResultsApplying the updated fatal CVD/clinical CVD multipliers led to a marked increase in the high-risk categories (109 (27%) vs. 244 (61%), (p < 0.001)), an absolute increase of 229%. Similarly, the number of low-risk categories decreased (190 (48%) vs. 81 (20%) (p < 0.001)).ConclusionThe current Dutch risk charts seriously underestimate the risk of clinical CVD, even in the first 10 years. Even when analyses are restricted to CVD events that required hospitalisation, true 10-year risks are more than double the currently estimated risks. Future guidelines may be revised to reflect these findings.

The high prevalence and burden of cardiovascular diseases (CVD) is largely attributable to unhealthy lifestyle factors such as smoking, alcohol consumption, physical inactivity and unhealthy food habits. Prevention of CVD, through the promotion of healthy lifestyles, appears to be a Sisyphean task for healthcare professionals, as the root causes of an unhealthy lifestyle lie largely outside their scope. Since most lifestyle choices are habitual and a response to environmental cues, rather than rational and deliberate choices, nationwide policies targeting the context in which lifestyle behaviours occur may be highly effective in the prevention of CVD. In this point-of-view article, we emphasise the need for government policies beyond those mentioned in the National Prevention Agreement in the Netherlands to effectively reduce the CVD risk, and we address the commonly raised concerns regarding ‘paternalism’.

Funding Acknowledgements Type of funding sources: None. Purpose Aortic dilatation is associated with acute aortic pathology. Cardiac magnetic resonance (CMR) data in asymptomatic elite athletes is lacking. Therefore, we investigated the prevalence of aortic dilatation in a cohort of elite-level athletes using CMR. Methods We performed a cross-sectional study of aortic dimensions among elite-level (national-, international-, Olympic-, Paralympic-level or comparable) athletes. All athletes were asymptomatic and examined during pre-participation screening. Each underwent CMR with 3D whole heart in diastole (1.5 mm voxel) for aortic measurements, next to cine imaging, late gadolinium enhancement (LGE), and T1-mapping. We defined dilatation as 38 and 40 mm at the aortic root (sinus of Valsalva cusp-cusp), 27 and 31 mm at the sinotubular junction, and 23 and 26 mm at the level of the diaphragm, in male- and female athletes, respectively. Athletes were grouped for having 0- (normal), 1-, 2- or 3 measurements above cut-off values. Results We screened 156 athletes, 41% female, with a mean age (±SD) of 28±7 and body surface area (BSA) of 2.0±0.2 m2. Mean aortic dimensions were 33±4 mm for the sinus of Valsalva, 28±3 mm for the sinotubular junction, 20±3 mm for the aorta at diaphragm. We observed indexed end-diastolic volumes (EDVi) of 122±20 and 123±20 ml/m2, indexed end-systolic volumes (ESVi) of 53±13 and 54±16 ml/m2, stroke volumes (SV) of 129±36 and 126±39 ml, and ejection fractions (EF) of 56±5 and 55±6 %, in the left- (LV) and right ventricle (RV), respectively Fifty-three (34%) athletes, of which 45% female, had 1 or 2 aortic measurements above conventional cut-off values (Table 1). Eleven (7%), 18% female, had 2 aortic measurements above cut-off values. No athlete had all 3 measurements above cut-offs values. Athletes with 2 dilated measurements compared to athletes with 1 or 0 dilated measurements, had greater LV EDVi (145±19 vs. 119±18 vs. 120±19 ml/m2, p&lt;0.001), greater RV EDVi (142±18 vs. 119±17 vs. and 122±20 ml/m2, p=0.002), greater LV ESVi (66±10 vs. 51±13 vs. 52±13 ml/m2, p=0.002), greater RV ESVi (66±10 vs. 53±13 vs. 53±17 ml/m2, p=0.039), greater LV SV (156±26 vs. 132±35 vs. 125±36 ml, p=0.020), and greater RV SV (152±25 vs. 130±34 vs. 121±41 ml, p=0.031), 2- vs, 1- vs. 0 dilated segments, respectively (Table 1, Figure 1). Athletes with dilated measurements had no LGE (excluding the hinge point), no difference in T1-mapping times, or LV- and RV EF, compared to athletes without dilated measurements. Conclusion One in three elite-athletes has dilatation in one or more aortic segments, including the sinus of Valsalva, sinotubular junction, or the aorta at diaphragm. Athletes with 2 dilated measurements (7%) had greater LV- and RV EDVi, ESVi, and SV, suggesting an association with ventricular volumes. Our findings in asymptomatic elite athletes, with normal EF and no LGE and comparable T1-mapping times, could be a sign of an outspoken physiological sports adaptation, instead of pathology.