Prescription of Lipid-Lowering and Antihypertensive Drugs Following Pictorial Information About Subclinical Atherosclerosis

Key Points Question Is provision of pictorial information on asymptomatic atherosclerosis to physicians and patients associated with prescribing of lipid-lowering or antihypertensive drugs during the following 465 days? Findings In this randomized clinical trial including 3532 participants with low to moderate cardiovascular disease risk, use of pictorial information on carotid intima-media thickness and carotid plaques based on ultrasonographic examination was evaluated. Physician prescription increased for lipid-lowering medications but not for antihypertensive drugs. Meaning The findings of this randomized clinical trial demonstrate that information on carotid intima-media thickness and the presence of carotid plaques can improve prescription of lipid-lowering drugs.

This supplementary material has been provided by the authors to give readers additional information about their work. eFigure 1: Pictorial information as presented to study participants and their primary care physicians (translated from Swedish).

Your carotid wall thickness, IMT, is illustrated as vascular age
Your value is shown in comparison to people of the same sex and age. The pointer goes from smaller to larger wall thickness. Green sector corresponds to the wall thickness of people who are at least 10 years younger than you, red sector who are at least 10 years older.

Variables Definitions
First prescription Any prescription for any lipid-lowering (ATC codes C10) or antihypertensive drug (ATC codes C03A, C07, C08, C09) registered in the Region Västerbotten database, among participants without a prescription for a lipid-lowering drug within 465 days before ultrasound examination. Education level Self-reported level of education (Västerbotten Intervention Program (VIP) questionnaire) -Low/middle: Basic education or high school -High: university education Previous myocardial infarction Self-reported previous myocardial infarction (VIP questionnaire) Yes/No Diabetes Diabetes status from oral glucose tolerance test at health examination before ultrasound examination (VIP data) or selfreported diabetes (VIP questionnaire). -

Diabetes -
No diabetes (either normal or with Isolated Impaired fasting glucose (IFG) or with Isolated Impaired glucose tolerance (IGT) or with both IFG and IGT) Systolic blood pressure Systolic blood pressure measured at health examination before ultrasound examination (VIP data). Diastolic blood pressure Diastolic blood pressure measured at health examination before ultrasound examination (VIP data).

Serum cholesterol
Total serum cholesterol measured at health examination before ultrasound examination (VIP data).

LDL-cholesterol
Low-density lipoprotein measured at health examination before ultrasound examination (VIP data). Prescription of antihypertensive drug at baseline Any prescription for any antihypertensive drug (ATC codes C03A, C07, C08, C09) within 465 days before the ultrasound examination and registered in the county council database, Yes/No Prescription of lipid-lowering drug at baseline Any prescription for any lipid-lowering drug (ATC codes C10) within 465 days before the ultrasound examination and registered in the county council database, Yes/No SCORE risk estimates SCORE estimated absolute 10-year risk in %, at baseline (VIP data). Year when participants were recruited to VIPVIZA Study participants were enrolled over a three-year period.
- Ascertained by the measurement of carotid intima media thickness (cIMT) in relation to cIMT thickness for persons of same age and sex in the reference population (ARIC), and presented as vascular age indicated with a gauge from green to red.
-Green: the intima media thickness corresponds to the average in persons at least 10 years younger than the chronological age -Yellow: the intima media thickness corresponds to the average in persons of same chronological age. The closer the pointer is to Green, the more the thickness of the wall corresponds to a 5-10 years younger person. -Orange: the intima media thickness corresponds to an average in persons of same chronological age. The closer the pointer is to Red, the more the thickness of the wall corresponds to a 5-10 years older person. Analysed for outcome -Lipid-lowering drugs n=1509 -Antihypertensive drugs n=1143 (including 2 deaths and 3 moved from area during the observation time) Analysed for outcome -Lipid-lowering drugs n=1453 -Antihypertensive drugs n=1094 (including 5 deaths and 2 moved from area during the observation time) With a baseline prescription -Lipid-lowering drug n=274 -Antihypertensive drugs n=640 With a baseline prescription -Lipid-lowering drug n=296 -Antihypertensive drugs n=655 1749 assigned to intervention group. 1783 assigned to control group.
• Declined participation n=345 • Died n=3 • Excluded due to significant carotid stenosis n=22 • Withdrew consent before randomization n=275 eTable 2: Number of subjects and percentages with a first prescription for any lipid-lowering drug among participants without a prescription at baseline (n=2962) in the VIPVIZA study. The results are presented for participants with or without carotid plaques and different vascular age (indicated by a gauge from Green through Yellow and Orange to Red with Green indicating a wall thickness of patients being at least 10 years younger than the actual age, and Red indicating at least 10 years older).