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Background and purpose: Over 50% of people aged >65 years have some degree of valvular heart disease (VHD), though most is mild. To understand the prognostic significance of VHD, we investigated its association with all-cause and cause-specific mortality.

Methods: The Oxford Valvular Heart Disease cohort study screened 4,009 participants aged >65 years between 2009-2016 to establish the presence and severity of VHD. We linked data to a civil mortality registry and undertook analysis using Kaplan-Meier curves, log rank tests, Cox regression and a Fine-Gray competing risks model.

Results: Data linkage was available for 3,511 participants, of whom 361 (10.3%) died (median 6.49 years follow-up). Valve abnormalities were common (n=2,645, 70.2%), though most was mild (prevalence 44.9%). Only 5.2% had clinically significant VHD. In adjusted analyses, neither mild nor clinically significant VHD were associated with increased all-cause mortality (HR 1.20, 95%CI: 0.96-1.51 and HR 1.47, 95%CI: 0.94-2.31 respectively). Conversely, advanced aortic sclerosis (prevalence 2.25%) and mitral annular calcification (MAC) (1.31%) were associated with an increased risk of death (HR 2.05, 95%CI: 1.28-3.30 and HR 2.51, 95%CI: 1.41-4.49 respectively). Mortality was highest for people with both advanced aortic sclerosis or MAC and clinically significant VHD (HR 4.38, 95%CI: 1.99-9.67).

Conclusions: The presence of advanced aortic sclerosis and MAC confers a worse outcome, particularly for patients with significant VHD, suggesting atherosclerosis is an important driver of mortality. Older patients with mild VHD can be reassured about their prognosis. The absence of an association between significant VHD and mortality may reflect the low disease prevalence.

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Deprescribing of antihypertensive medications is recommended for some older patients with polypharmacy and multimorbidity when the benefits of continued treatment may not outweigh the harms. The presentation will focus on the current evidence for deprescribing antihypertensive medications in primary care with particular focus on the recent OPTIMISE randomized, controlled, non-inferiority trial conducted in primary care in England. This study enrolled participants aged 80 years and older, with systolic blood pressure lower than 150 mmHg and prescription for 2 or more antihypertensive medications. Participants were randomized (1:1) to a strategy of antihypertensive medication reduction (removal of 1 drug) or usual care, in which no medication changes were mandated. The primary outcome was systolic blood pressure lower than 150 mmHg at 12-week follow-up. Among 569 patients randomized (mean age, 84.8 years), 534 (93.8%) completed the trial. Overall, 229 (86.4%) patients in the intervention group and 236 (87.7%) patients in the control group had a systolic blood pressure lower than 150 mmHg at 12 weeks (adjusted RR, 0.98 [97.5% 1-sided CI, 0.92 to ∞]). Medication reduction was sustained in 187 (66.3%) participants at 12 weeks. Mean change in systolic blood pressure was 3.4 mm Hg (95% CI, 1.1 to 5.8 mm Hg) higher in the intervention group compared with the control group. These findings suggest antihypertensive medication reduction is not associated with substantial change in blood pressure control in some older patients, although further research is needed to understand long-term clinical outcomes.

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Objectives To assess the accuracy of semi-automatic assisted telephone triage in patients with acute chest discomfort against the diagnosis acute coronary syndrome (ACS) or other life threatening events (LTEs).

Methods Cross-sectional study with telephone conversations of 2,023 patients with acute chest discomfort (pain, pressure, tightness, or discomfort) who called out-of-hours services for primary care (OHS-PC) between 2014 and 2016. Sensitivity, specificity, positive and negative predicted values were calculated for a high urgency (patient seen within one hour) against the diagnoses ACS and other LTEs. Diagnoses were retrieved from the patient’s medical records in general practice, including hospital specialists discharge letters.

Results Of 2,023 patients who called for chest discomfort, 227 (11.2%) had an ACS (men 14.9%, women 8.2%) and 58 (2.9%) had another LTE (men 3.6%, women 2.3%). The sensitivity and specificity of a high Netherlands Triage Standard (NTS) urgency allocation against ACS/other LTEs were 0.73 (95% CI 0.68-0.78) and 0.43 (95% CI 0.40-0.45). In 13.2% of the calls, the triage nurse overruled the NTS urgency, mostly by upscaling (11.0%). The sensitivity and specificity of the final urgency allocation were 0.86 (95% CI 0.81-0.90) and 0.34 (95% CI 0.32-0.37). The positive and negative predictive values of the final urgency were 0.18 (95% CI 0.17-0.19) and 0.94 (95% CI 0.92-0.95).

Conclusions The semi-automatic triage NTS tool underestimated the urgency in 27% of patients with ACS/other LTEs. Overruling by triage nurses improved safety, but still 14% of men and women with ACS/other LTEs received a too low urgency, while efficiency remained poor.

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Background and purpose: Counselling to promote healthier lifestyle habits for patients at high cardiovascular risk has been lifted during recent years, however, less is known on the participants experiences of lifestyle counselling in primary care. To enhance the care of patients at high cardiovascular risk and address their risk for future cardiovascular disease (CVD), we started a one-year, structured lifestyle program at a Swedish primary care unit. The purpose of the present study was to explore and describe core elements of lifestyle counselling as experienced by the participants in a one-year lifestyle counselling program.

Methods: A qualitative content analysis, with an inductive approach, was performed to describe participants experience of lifestyle counselling. Sixteen patients (eight men and eight women, aged 51-75 years) that participated in the program and three community health nurses (CHN) that provided the counselling, were interviewed.

Results: The results revealed five dimensions of lifestyle counselling contributing to describe the participants experiences of lifestyle counselling. These core elements were; collaboration, understanding of illness, goal setting, long-term support and a structure within the primary care unit that supports lifestyle counselling. The theme “Lifestyle counselling – a long-term commitment based on partnership” emphasised that lifestyle counselling encompassed a partnership based on an equal and mutual collaboration between patients and CHNs.

Conclusions: The informants declared that counselling had to be based on partnership based on mutual respect, recognising the patient as expert on his/ her current life situation and that both parties had to engage in the process of lifestyle change.

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Heart failure (HF) together with type 2 diabetes (T2D) and chronic kidney disease (CKD) are major pandemics of the twenty first century. In a cohort of people with new onset HF, hospitalisations and deaths are high in patients with T2D or CKD, and worst in those with both comorbidities. Whilst outcomes have improved over time for patients with HF and comorbid T2D, similar trends were not seen in those with comorbid CKD. Strategies to prevent and manage CKD in people with HF are urgently needed. Focusing on the early identification and management of people with CKD in primary care therefore needs urgent attention.

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Aims: To evaluate whether integrated care for atrial fibrillation (AF) can be safely orchestrated in primary care.

Methods and Results: The ALL-IN trial was a cluster randomised, open-label, pragmatic non-inferiority trial performed in primary care practices in the Netherlands. We randomised 26 practices: 15 to the integrated care intervention and 11 to usual care. The integrated care intervention consisted of (i) quarterly AF check-ups by trained nurses in primary care, also focusing on possibly interfering comorbidities, (ii) monitoring of anticoagulation therapy in primary care, and finally (iii) easy-access availability of consultations from cardiologists and anticoagulation clinics. The primary endpoint was all-cause mortality during 2 years of follow-up. In the intervention arm, 527 out of 941 eligible AF patients aged ≥ 65 years provided informed consent to undergo the intervention. These 527 patients were compared with 713 AF patients in the control arm receiving usual care. Median age was 77 (interquartile range 72-83) years. The all-cause mortality rate was 3.5 per 100 patient-years in the intervention arm versus 6.7 per 100 patient-years in the control arm (adjusted hazard ratio 0.55; 95% confidence interval (CI) 0.37 to 0.82). For non-cardiovascular mortality, the adjusted hazard ratio was 0.47 (95% CI 0.27 to 0.82). For other adverse events no statistically significant differences were observed.

Conclusion: In this cluster randomised trial, integrated care for elderly AF patients in primary care showed a 45% reduction in all-cause mortality when compared to usual care.