146 Chapter 6 as compared to interview (Supplementary table 3). Otherwise, no major differences by data collection source were observed in patients’ characteristics, attainment of risk factors, treatment, or the associations between educational level and target attainment or treatment. Similarly, sensitivity analysis by CHD diagnostic category showed no major differences in study outcomes (Supplementary File 2). DISCUSSION Summary of main findings In our study of 13,884 patients with CHD from 29 countries in Europe, the Middle-East, North- and South America, and Asia, we observed reasonable recording of most risk factors, high use of most medication classes, but poor attainment of risk factor targets and participation in cardiac rehabilitation. Patients with higher education are generally more likely to meet risk factor targets, to receive medical treatment, and to participate in cardiac rehabilitation, although these associations varied in different country income groups. Recording Our findings show that blood pressure and smoking were registered in almost all patients, however recording for other risk factors such as blood lipids, Hba1c, and BMI were modest, and very low for waist circumference. Previous studies similarly found satisfactory recording of blood pressure in primary care (15,16), and of blood pressure and smoking in secondary prevention (17), and also reported incomplete data on other risk factors. We also observed lower risk factor recording for some variables in data collected from pre-existing sources as compared to interview, which can be partly explained by the structure of these data sources as some variables are not collected. Overall, the low level of recording observed is cause for concern because risk factor recording is a key step for efficient counseling, adaptation to therapy, and follow-up (15–17). Target attainment Our results show poor levels of target attainment in secondary prevention, especially for weight-related risk factors and blood lipids. These findings are in line with previous studies (6,17–19), and these highlight the need to improve risk factor control in CHD patients. Patients with higher educational level were generally more likely to meet risk factor targets, although these associations varied by country income group and risk factor. A higher educational level was associated with meeting the target for smoking in all country-income groups; while a negative association was observed for waist circumference and LDL targets in UMICs, and for BMI targets in LMICs. A positive association between educational level and risk factor target attainment has been reported in previous studies (7,19). In EUROASPIRE V, CHD patients with primary or secondary education were less likely to meet risk factor targets for most cardiovascular risk factors compared to patients with tertiary education (7). Higher educational level was associated with achieving physical activity targets in Swedish CHD patients (19), and with having a healthy diet and not smoking in participants of the community-based PURE Study
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