Images of atherosclerosis may boost patient adherence to CVD prevention

Showing patients and their primary care doctors pictorial representations of carotid plaque may prompt greater adherence to lifestyle and medication interventions, resulting in lower cardiovascular disease (CVD) risk within one year, according to a study published Dec. 3 in The Lancet.

The randomized trial featured more than 3,500 individuals aged 40 to 60 who participated in a community-based CVD prevention program in Sweden. All participants had at least one cardiovascular risk factor and underwent blood sampling, a survey of clinical risk factors and ultrasound assessment for carotid intima media wall thickness and plaque formation.

Half of the patients were randomized to the control group, which received risk factor screening and CVD prevention advice based on clinical guidelines. In the intervention group, pictorial representations of carotid artery plaque were given to patients and their primary care doctors.

These images presented atherosclerosis as a color-coded representation of vascular age, highlighting when the individual’s biological age and chronological age were misaligned. Plaque formation was also shown as a traffic light for each carotid artery, with green circles indicating no plaque formation and red indicating that plaque was detected. Short written information about how atherosclerosis can progress was also included, including how the process is modifiable with a healthy lifestyle and drug treatment.

A nurse called to follow up with patients about these results two to four weeks after the scans, and the images were sent again to patients at six months to reinforce the message.

This extra effort appeared to have some effect, as patients in the intervention arm had lower totals at a one-year followup on two commonly used risk scores, the Framingham Risk Score (FRS) and the European systematic coronary risk evaluation (SCORE). FRS scores were 1.07 points lower on average in patients who received their ultrasound images, while SCORE results were 0.16 points lower—small but statistically significant differences.

Total and LDL cholesterol levels decreased in both groups but significantly more in the intervention patients, who also demonstrated greater use of lipid-lowering medications. The differences between groups in other components of the risk scores weren’t statistically significant, although blood pressures and body weights were slightly lower among patients who had received the visual representations of their atherosclerosis.

"Cardiovascular disease is the leading cause of death in many countries, and despite a wealth of evidence about effective prevention methods from medication to lifestyle changes, adherence is low,” lead author Ulf Näslund, PhD, from Umea University in Sweden, said in a press release. “Information alone rarely leads to behavior change and the recall of advice regarding exercise and diet is poorer than advice about medicines.

“Risk scores are widely used, but they might be too abstract, and therefore fail to stimulate appropriate behaviors. This trial shows the power of using personalized images of atherosclerosis as a tool to potentially prompt behavior change and reduce the risk of cardiovascular disease."

Näslund and colleagues noted most of their participants were at low to intermediate risk of CVD, which could explain why the intervention’s effects, while statistically significant, weren’t more substantial. This notion is supported by the finding that the greatest overall improvements were observed among participants with the highest risk to begin with.

The authors said additional studies will be needed to determine whether the improvements in risk scores translate to fewer adverse cardiovascular events in the long run.

“If clinical event rates are reduced in the follow-up studies, this simple intervention could easily be applied in general practice in other similar settings,” they wrote. “Our study supports further attempts to solve the major problem of prevention failure because of low adherence, despite effective, cost-effective and evidence-based medications and methods for a healthier lifestyle.”