Reviving Early Diagnosis of CardioVascular Disease

The early stages of cardiovascular disease (CVD) generally cause non-specific
or atypical symptoms that patients often do not spontaneously mention to their
general practitioner. This makes that new onset CVD is easily missed. A more
proactive diagnostic strategy has the potential to uncover these frequently
missed early stages, thus creating an opportunity for early intervention that
may prevent progression into chronic CVD or devastating acute cardiovascular
events. This is of particular importance for cardiovascular diseases with
evidence-based therapies known to improve prognosis, such as coronary artery
disease (CAD), atrial fibrillation (AF) and heart failure (HF).

Previous studies have shown that patients with type 2 diabetes (T2D) or chronic
obstructive lung disease (COPD) are at highly increased risk of developing CVD,
and that 20-65% of these patients have 'concealed' CVD. In the current study,
we will test a newly developed Early Diagnostic Strategy, aimed at these high
risk patients and blended in with the primary care disease management programs
these patients routinely participate in.

Objective of this study is to compare the diagnostic yield of the Early
Diagnosis Strategy to usual care, in terms of detection and subsequent
treatment of previously unrecognized CAD, AF and HF.

A cluster randomized diagnostic trial with 40 primary care practices at the
unit of randomization.

The two stage Early Diagnostic Strategy, consisting of the Early Diagnosis
Questionnaire (stage 1) to be filled in at home prior to the next routine
visit, followed if necessary by physical examination of legs, heart and lungs,
electrocardiography and BNP-measurement (stage 2).

As our new Early Diagnosis Strategy is to be blended in with the
well-established primary care disease-management programs for COPD and T2D, the
burden associated with participation will be relatively low. No extra visits
will be required; patients will be asked to fill out the questionnaires before
their regular visits. Our strategy depends solely on non-invasive and minimally
invasive (blood taking), standard diagnostic procedures. In case of suspected
CVD, standard diagnostic procedures will be applied according to
(inter)national guidelines on CVDs. There is a potential benefit associated
with participation, as we aim to uncover early stage CVD that might not have
been detected otherwise, and for which early treatment is prognostically
beneficial. Minors and persons with severe cognitive impairment or who are not
proficient in Dutch will not be included.