Visualization of Asymptomatic Atherosclerotic Disease for Optimum Cardiovascular Prevention

Cardiovascular Diseases Clinical Trial

— VIPVIZA  

Official title:

Direct VIsualiZAtion of Asymptomatic Atherosclerotic Disease for Optimum Cardiovascular Prevention. A Population Based Pragmatic Randomised Controlled Trial Within Västerbotten Intervention Programme (VIP) and Ordinary Care.

Clinical Trial Details — Status: Active, not recruiting

Administrative data

• NCT number: NCT01849575
• Other study ID #: VIPVIZA version 20121204
• Status: Active, not recruiting
• Phase: N/A
• Start date: April 7, 2013
• Est. completion date: December 31, 2027

Study information

• Verified date: January 2024
• Source: Umeå University
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

The purpose of VIPVIZA is to assess the impact of pictorial information about asymptomatic atherosclerotic disease to both physician and patient, for improving physicians' adherence to prevention guidelines and patient perception and understanding of the cardiovascular disease (CVD) risk and consequent motivation for prevention. The intervention effect is assessed by differences between randomization groups in the primaryboutcome Framingham Risk Score (FRS) and the secondary outcomes the Systematic COronary Risk Evaluation (SCORE) as well as changes in these scores after one, three and six years. Secondary outcomes are also atherosclerotic disease progression, as assessed by repeated carotid ultrasound examination after three and six years, as well as the prevalence of acute events and mortality after 10 years . Social, psychological and cognitive determinants of behavioral change as well as the intervention impact on novel biomarkers will also be explored.

Description:

Project description

The main objective of this project is to contribute to improved primary prevention of cardiovascular disease through the provision of a visual image and pictorial report of atherosclerosis while still asymptomatic. The image and report are seen and discussed by both physician and patient in order to improve guideline adherence and patient perception and understanding of the CVD risk and consequent motivation for prevention. The specific objectives include: 1. To assess the prevalence of asymptomatic atherosclerotic disease in men and women through identification of carotid plaques and measurement of carotid intima-media thickness (CIMT), and to relate plaques and CIMT to clinically estimated CVD risk factors and risk scores; 2. To explore the impact of pictorial representations of atherosclerosis on physicians´ adherence to prevention guidelines, and on individuals' quality of life, preventive measures, risk factor control and progress of atherosclerotic disease over the course of three and six years, as well as on premature CVD morbidity and mortality over the course of 5 and 10 years; 3. To evaluate how individuals' social, psychological, and cognitive characteristics relate to health behaviours, atherosclerosis and CVD risk at baseline and progression of any atherosclerosis; 4. To investigate biomarkers in relation to CIMT and plaques at baseline, changes in conventional CVD risk markers and lifestyle, and progression of atherosclerosis.

Survey of the field Primary prevention of CVD often fails due to poor adherence among practitioners and patients to evidence-based prevention guidelines on effective modification of risk factors by lifestyle change and pharmacological treatment. Contributory factors include poor communication about the CVD risk by the physician and inaccurate risk perception among patients. The risk message is usually communicated verbally or numerically, while potentially more effective visual tools are seldom used. For the clinical assessment of CVD risk the FRS and the European SCORE are most widely used. However, evidence that their use translates into reduced CVD morbidity and mortality is scarce. These risk scores focus on high-risk individuals, despite 60-70% of all CVD events occurring among individuals at low or intermediate risk for CVD. They might also be too abstract to lead to accurate risk perception and to motivate individuals to take preventive actions; information alone seldom results in rational behavior modification. VIPVIZA takes a different approach from current practice for the prevention of CVD. Instead of being based solely on indirect risk factors, this project evaluates the atherosclerotic disease itself while it still is subclinical, providing improved assessment, communication and perception of the CVD risk and hence greater motivation for prevention. This is achieved with ultrasonography of medium sized arteries with assessment of CIMT and existing atherosclerotic plaques.

Design, setting and study population:

The study is a pragmatic randomised open-label controlled trial with blinded evaluators (PROBE). VIPVIZA is integrated in and added to the ordinary Västerbotten Intervention Programme (VIP). Individuals with at least one clinical CVD risk factor were invited to the VIPVIZA trial when they participated in VIP (n=4177), resulting in inclusion of 3532 participants. Baseline visits with ultrasound examinations were carried out from April 29 2013 to June 7 2016. Participants were consecutively and randomly allocated to two groups (intervention and control group) using a computer-generated randomization list. The ultrasound examinations in VIPVIZA at baseline as well as after three and six years are performed at the hospitals in the three cities/towns (Umeå, Skellefteå, Lycksele), and in remote rural areas at primary health care centres. Risk factor measurements and questionnaires at follow-up after one, three and six years are carried out for participants living in Umeå at the Clinical Research Centre at Umeå University Hospital, and for participants in the rest of the county at their local primary health care center. Both groups are managed according to clinical guidelines for CVD prevention within primary care (not by the study team).

Intervention At baseline, pictorial representation of the carotid ultrasound results was given to each participant in the intervention group and their primary care physician. Atherosclerosis was presented as vascular age, with a gauge ranging from green through yellow, orange and red to illustrate the individual's biological age compared to chronological,age. A red or a green circle, like a traffic light, illustrated detected or no detected plaque, respectively. Brief written information about atherosclerosis as a dynamic process that is modifiable by a healthy lifestyle and pharmacological treatment, an interpretation of the result and general advice on CVD prevention were included. After 2-4 weeks, participants received a follow-up phone call by a research nurse in order to reassure and give additional information as needed. The same pictorial information was repeated to participants after 6 months. No information about the ultrasound result was given to the control group and their physicians.

At three- and six-year follow-up both the intervention and the control group participants and their respective primary care physician receive information about ultrasound results with the same format as was given to the intervention group at baseline. Thus, the intervention is completed at the time-point for three-year follow-up. After that the two groups are continuously followed through registries and compared with respect to atherosclerosis development and hard outcomes.

Data collection:

Clinical risk factors for cardiovascular disease: Measured at the baseline VIP health survey, at 1-, 3- and 6-year follow-up (blood pressure, lipids, and glucose, BMI and waist circumference).

Questionnaires: The VIP questionnaire covers health, socioeconomic situation, quality of life (RAND 36), lifestyle (physical activity, tobacco and alcohol consumption, diet), working conditions, social network. Validated psychometric instruments at baseline and 3-year follow-up included health literacy, coping strategies, an optimism-pessimism scale, self-efficacy, HADS and self-rated risk of CVD. Perceptions about preventive medication and a stress questionnaire at the 3-year follow-up. At 3-year follow-up questions on health literacy, coping strategies and optimism/pessimism are replaced by questionnaires on personality and dental care.

Carotid ultrasound examinations are performed at baseline, after 3 and6 years according to a standardized protocol.

Interviews: With subsamples of participants after the first, second and third ultrasound examination, and with primary care physicians after the first ultrasound examination.

Stored samples of blood to the Medical Biobank: This is done at the baseline VIP visit and at 3- and 6-year follow-up among participants, to be used for analyses of novel biomarkers Register data: Prescriptions, visits and risk factor measurements from the medical records system in Västerbotten County. Dental health and dental radiological examinations from Dental care. The Prescriptions register, Hospitalizations register and Causes of deaths register at the National Board of Health and Welfare. In addition, physical and psychological functioning and blood-group at military patterning at age around 18 from the Conscripts registry (for male participants only), educational level and income from Statistics Sweden and air pollutants by geographical region in the County of Västerbotten.

Time plan The study progress is largely according to the plan. Baseline examinations were conducted April 2013-June 2016, the 1-year follow-up examinations June 2014-August 2017, and the 3-year examinations September 2016 - June 2019. The six-year follow-up examinations started December 2019 which is a delay of 6 months due to administrative reasons. Register data from medical records, Statistics Sweden, the Conscripts register, Air-borne pollutants are underway April 2020. Data on morbidity and mortality will be retrieved in 2027, i.e. one year later than 10 years after trial start due to delay until data on events has been entered into the registries.

Ethical approval:

Study protocol version 4.0:

The VIPIVZA trial: Dnr 2011-445-32M date Feb 7 2012. Amendment 1: Dnr 2012-463-32M date December 19 2012. Amendment 2: Dnr 2013 373-32M date October 15 1013. Amendment 3: Dnr 2016-245-32M date May 31 2016. Amendment 4: Dnr 2017-95-32M date February 27 2017. Amendment 5: Dnr 2018-182-32 date May 28 2018.

Study protocol version 5.0:

Amendment 6: Dnr 2018-482-32M Date December 27 2018. Amendment 7: Dnr 2019-04619 Date September 24 2019.

Recruitment information / eligibility

• Status: Active, not recruiting
• Enrollment: 3532
• Est. completion date: December 31, 2027
• Est. primary completion date: November 10, 2017
• Accepts healthy volunteers: Accepts Healthy Volunteers
• Gender: All
• Age group: 40 Years to 60 Years

Eligibility

Inclusion Criteria:

• Participant in the Västerbotten Intervention Programme

and

• 40 years old and a history of CVD at age < 60 years among first-degree relative

or

• 50 years old and at least one of the following six criteria:

• a history of CVD at age < 60 years among first-degree relative,

• smoking,

• diabetes,

• hypertension,

• S-LDL-cholesterol =4.5 mmol/L,

• abdominal obesity

or

• 60 years old

Exclusion Criteria:

• Stenosis =50% of the carotid lumen

Related Conditions & MeSH terms

• Cardiovascular Diseases

Intervention

Behavioral:
• Intervention
Information about carotid ultrasound results to the participant and his/her primary care physician in the form of atherosclerosis highlighted graphically in color against normal vascular age patterns and as plaque formation. General information about atherosclerosis as a dynamic modifiable process and recommendation to follow clinical guidelines for risk factor control. After 2-4 weeks a follow-up call by a research nurse, to give additional information and reassurance, if needed. Identical information to the study participant is sent by post after 6 months. CVD risk factors are managed according to clinical guidelines within primary health care during the entire study period.

Locations

Country	Name	City	State
Sweden	Clinical Reseach Center Umeå University Hospital	Umeå

Sponsors (2)

Lead Sponsor	Collaborator
Umeå University	Västerbotten County Council, Sweden

Country where clinical trial is conducted

Sweden, 

References & Publications (21)

Ali H, Näslund U, Nyman E, Grönlund C. Translation of atherosclerotic disease features onto healthy carotid ultrasound images using domain-to-domain translation. Biomedical Signal Processing & Control. 2023

Andersson EM, Johansson H, Nordin S, Lindvall K. Cognitive and emotional reactions to pictorial-based risk communication on subclinical atherosclerosis: a qualitative study within the VIPVIZA trial. Scand J Prim Health Care. 2023 Mar;41(1):69-80. doi: 10. — View Citation

Bengtsson A, Lindvall K, Norberg M, Fharm E. Increased knowledge makes a difference! - general practitioners' experiences of pictorial information about subclinical atherosclerosis for primary prevention: an interview study from the VIPVIZA trial. Scand J — View Citation

Bengtsson A, Nyman E, Gronlund C, Wester P, Naslund U, Fharm E, Norberg M. Multi-view carotid ultrasound is stronger associated with cardiovascular risk factors than presence of plaque or single carotid intima media thickness measurements in subclinical a — View Citation

Fortuin-de Smidt M, Bergman F, Gronlund C, Hult A, Norberg M, Wennberg M, Wennberg P. Early adulthood exercise capacity, but not muscle strength, associates with subclinical atherosclerosis 40 years later in Swedish men. Eur J Prev Cardiol. 2023 Mar 27;30 — View Citation

Holmberg H, Sjolander M, Glader EL, Naslund U, Carlberg B, Norberg M, Sjalander A. Time to initiation of lipid-lowering drugs for subclinical atherosclerosis: sub-study of VIPVIZA randomized controlled trial, with single-arm cross-over. Eur Heart J Open. — View Citation

Kovrov O, Landfors F, Saar-Kovrov V, Naslund U, Olivecrona G. Lipoprotein size is a main determinant for the rate of hydrolysis by exogenous LPL in human plasma. J Lipid Res. 2022 Jan;63(1):100144. doi: 10.1016/j.jlr.2021.100144. Epub 2021 Oct 26. — View Citation

Lindahl B, Norberg M, Johansson H, Lindvall K, Ng N, Nordin M, Nordin S, Naslund U, Persson A, Vanoli D, Schulz PJ. Health literacy is independently and inversely associated with carotid artery plaques and cardiovascular risk. Eur J Prev Cardiol. 2020 Jan — View Citation

Naslund U, Ng N, Lundgren A, Fharm E, Gronlund C, Johansson H, Lindahl B, Lindahl B, Lindvall K, Nilsson SK, Nordin M, Nordin S, Nyman E, Rocklov J, Vanoli D, Weinehall L, Wennberg P, Wester P, Norberg M; VIPVIZA trial group. Visualization of asymptomatic — View Citation

Naslund U, Norberg M, Wennberg P. The TANSNIP-PESA trial is not the end of the story. Eur Heart J. 2023 May 1;44(17):1574. doi: 10.1093/eurheartj/ehad135. No abstract available. — View Citation

Nordin S, Norberg M, Braf I, Johansson H, Lindahl B, Lindvall K, Nordin M, Nyman E, Vallstrom C, Wennberg P, Liv P, Naslund U. Associations between emotional support and cardiovascular risk factors and subclinical atherosclerosis in middle-age. Psychol He — View Citation

Nyman E, Gronlund C, Vanoli D, Liv P, Norberg M, Bengtsson A, Wennberg P, Wester P, Naslund U; VIPVIZA trial group. Reduced progression of carotid intima media thickness by personalised pictorial presentation of subclinical atherosclerosis in VIPVIZA-A ra — View Citation

Nyman E, Lindqvist P, Naslund U, Gronlund C. Risk Marker Variability in Subclinical Carotid Plaques Based on Ultrasound is Influenced by Cardiac Phase, Echogenicity and Size. Ultrasound Med Biol. 2018 Aug;44(8):1742-1750. doi: 10.1016/j.ultrasmedbio.2018. — View Citation

Nyman E, Liv P, Wester P, Naslund U, Gronlund C. Carotid wall echogenicity at baseline associates with accelerated vascular aging in a middle-aged population. Int J Cardiovasc Imaging. 2023 Mar;39(3):575-583. doi: 10.1007/s10554-022-02760-3. Epub 2023 Jan — View Citation

Nyman E, Vanoli D, Naslund U, Gronlund C. Inter-sonographer reproducibility of carotid ultrasound plaque detection using Mannheim consensus in subclinical atherosclerosis. Clin Physiol Funct Imaging. 2020 Jan;40(1):46-51. doi: 10.1111/cpf.12602. Epub 2019 — View Citation

Salvador D Jr, Liv P, Norberg M, Pahud de Mortanges A, Saner H, Glisic M, Nicoll R, Muka T, Nyman E, Bano A, Naslund U. Changes in fasting plasma glucose and subclinical atherosclerosis: A cohort study from VIPVIZA trial. Atherosclerosis. 2023 Oct 17:1173 — View Citation

Schulz PJ, Lindahl B, Hartung U, Naslund U, Norberg M, Nordin S. The right pick: Does a self-assessment measurement tool correctly identify health care consumers with inadequate health literacy? Patient Educ Couns. 2022 Apr;105(4):926-932. doi: 10.1016/j. — View Citation

Sjolander M, Carlberg B, Norberg M, Naslund U, Ng N. Prescription of Lipid-Lowering and Antihypertensive Drugs Following Pictorial Information About Subclinical Atherosclerosis: A Secondary Outcome of a Randomized Clinical Trial. JAMA Netw Open. 2021 Aug — View Citation

Sommar JN, Norberg M, Gronlund C, Segersson D, Naslund U, Forsberg B. Long-term exposure to particulate air pollution and presence and progression of carotid artery plaques - A northern Sweden VIPVIZA cohort study. Environ Res. 2022 Aug;211:113061. doi: 1 — View Citation

Vanoli D, Lindqvist P, Wiklund U, Henein M, Naslund U. Fully automated on-screen carotid intima-media thickness measurement: a screening tool for subclinical atherosclerosis. J Clin Ultrasound. 2013 Jul-Aug;41(6):333-9. doi: 10.1002/jcu.22041. Epub 2013 M — View Citation

Vanoli D, Wiklund U, Lindqvist P, Henein M, Naslund U. Successful novice's training in obtaining accurate assessment of carotid IMT using an automated ultrasound system. Eur Heart J Cardiovasc Imaging. 2014 Jun;15(6):637-42. doi: 10.1093/ehjci/jet254. Epu — View Citation

* Note: There are 21 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Other	FRS, Adjusted for Baseline Values	FRS=Framingham risk score. Composite gender-specific algorithm used to estimate the 10-year cardiovascular risk of an individual, based on levels of blood pressure, total cholesterol, LDL-cholesterol, systolic blood pressure, treatment for high blood pressure, diabetes, smoking and age. Minimum value=0, maximum value 100. Higher score means a worse outcome, i.e. a higher risk of cardiovascular diseases.	Follow-up after three years during September 5 2016 - May 28 2019
Other	SCORE Adjusted for Baseline Levels	SCORE: European systematic coronary risk evaluation. Risk of death (%) in myocardial infarction within 10 years expressed as statistical assessment based on smoking, systolic blood-pressure, blood cholesterol, age and sex.; SCORE is evaluated as a continuous variable with Minimum value=0%, maximum value=100%. Higher score means a worse outcome, i.e. a higher risk of cardiovascular diseases.	Three years of follow-up, data collected during September 5 2016 - May 28 2019
Primary	FRS	Framingham risk score. Composite gender-specific algorithm used to estimate the 10-year cardiovascular risk of an individual, based on levels of blood pressure, total cholesterol, LDL-cholesterol, systolic blood pressure, treatment for high blood pressure, diabetes, smoking and age. Minimum value=0, maximum value 100. Higher score means a worse outcome, i.e. a higher risk of cardiovascular diseases.	one year
Secondary	SCORE	SCORE: European systematic coronary risk evaluation. Risk of death (%) in myocardial infarction within 10 years expressed as statistical assessment based on smoking, systolic blood-pressure, blood cholesterol, age and sex.; SCORE is evaluated as a continuous variable with Minimum value=0%, maximum value=100%. Higher score means a worse outcome, i.e. a higher risk of cardiovascular diseases.	Follow-up after one year
Secondary	Hospitalizations Due to Stroke, Myocardial Infarctions and Re-vascularizations	Data will be collected from the In-patient registry at the National Board of Health and Welfare.	10 years
Secondary	Total Mortality and Cause-specific Mortality Due to Myocardial Infarctions and Stroke	Data will be collected from the Causes of Deaths registry at the National Board of Health and Welfare.	10 years
Secondary	Total Mortality	Data will be collected from computerized medical records from hospital care in the county, regional quality registry on myocardial infarctions and from the In-patient registry at the National Board of Health and Welfare.	10 years
Secondary	Carotid Atherosclerosis	Carotid intima media thickness	3 years after baseline