Cardiologists’ cardiovascular profile and lifestyle habits are poorly known worldwide. To offer a snapshot of the personal health habits of Italian cardiologists, the Survey on Cardiac Risk Profile and Lifestyle Habits in a Cohort of Italian Cardiologists (SOCRATES) was undertaken. A Web-based electronic self-reported survey, accessible through a dedicated Web site, was used for data entry, and data were transferred through the Web to a central database. The survey was divided into 4 sections: baseline characteristics, medical illnesses and traditional cardiovascular risk factors, lifestyle habits, and selected medication use. The e-mail databases of 3 national scientific societies were used to survey a large and representative sample of Italian cardiologists. During the 3-month period of the survey, 1,770 of the 5,240 cardiologists contacted (33.7%) completed and returned ≥1 sections of the questionnaire. More than 49% of the participants had 1 of the 5 classic risk factors (hypertension, hypercholesterolemia, active smoking, diabetes, and previous vascular events). More than 28% of respondents had 2 to 5 risk factors, and only 22.1% had none and therefore, according to age and gender, could be considered at low to intermediate risk. Despite the reported risk factors, >90% of cardiologists had a self-reported risk perception quantified as mild, such as low or intermediate. Furthermore, overweight and obesity, physical inactivity, and stress at work or at home were commonly reported, as well as limited use of cardiovascular drugs, such as statins or aspirin. In conclusion, the average cardiovascular profile of Italian cardiologist is unlikely to be considered ideal or even favorable according to recent statements and guidelines regarding cardiovascular risk.
Cardiovascular disease (CVD) remains the leading cause of death in developed countries. The cornerstone of CVD prevention is the promotion of a healthy lifestyle and the appropriate identification and treatment of traditional cardiovascular risk factors. Indeed, a growing body of evidence indicates that simple changes in lifestyle and diet decrease the clinical impact of several risk factors and improve long-term outcomes in primary and secondary prevention settings. Physicians involved in primary prevention are key players in CVD risk control strategies. In addition, cardiologists frequently provide counseling and education for CVD risk reduction to citizens and patients and therefore likely serve as role models for behavioral change. Thus, it can be expected that cardiologists who know their own risk factor profiles and who follow healthy lifestyle behaviors will be more ardent proponents of risk factor modifications for their patients. Unfortunately, cardiologists’ cardiovascular profile and lifestyle habits are poorly known worldwide. A survey assessing the personal healthy habits of American cardiologists showed that cardiologists as a group appear to have lower rates of cardiovascular risk factors and follow healthier lifestyles compared with the general adult United States population. To date, similar studies have not been conducted among cardiologists in the Mediterranean area. Thus, to offer a snapshot of the personal health habits of Italian cardiologists, the Survey on Cardiac Risk Profile and Lifestyle Habits in a Cohort of Italian Cardiologists (SOCRATES) was undertaken.
Methods
The e-mail databases of 3 national scientific societies (Associazione Nazionale Medici Cardiologi Ospedalieri, Associazioni Regionali Cardiologi Ambulatoriali, and the Italian Association for Cardiovascular Prevention, Rehabilitation and Epidemiology) were used to survey a large and representative sample of Italian practicing cardiologists.
A Web-based electronic self-reported survey, accessible through a dedicated Web site, was used for data entry, and data were transferred through the Web to a central database. Anonymity was provided for all subjects.
The Web-based survey was divided into 4 sections: baseline characteristics, medical illnesses and traditional cardiovascular risk factors (yes or no), lifestyle habits (multiple choice), and selected medication use. Baseline demographics included age, gender, height, weight, body mass index, and waist circumference. A list of previous or current CVDs, such as self-reported history of vascular events, hypertension, hypercholesterolemia, and diabetes, was collected. In addition, physical and biochemical parameters, such as heart rate and blood pressure (self-collected at the time of questionnaire compilation), total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides, serum creatinine, and fasting glucose were reported. Cardiologists were asked to indicate the timing of their blood analysis (within the past 12 months or previously). Personal habits included smoking status, exercise habits, and dietary servings of fruits, vegetables, fish, and fats. Questions regarding stress at work or at home were also posed. Participants were asked to indicate the types of cardiovascular or metabolic medications used and to provide data on any target organ damage and/or subclinical atherosclerosis that were available at the time of the questionnaire. Finally, self-reported evaluations of their own cardiovascular risk profile assessments (low, intermediate, or high) were requested. The data collection instrument was designed using a multiple-choice format, with pull-down menus or check boxes and obligatory (required) items to be answered, to reduce the risk for confounding responses.
The survey was conducted through the Web site http://www.socrates.qbgroup.it . In January 2012, e-mails were sent to 5,240 cardiologists (mean age 53 years, range 28 to 89, 26% women) among current members of Associazione Nazionale Medici Cardiologi Ospedalieri, Associazioni Regionali Cardiologi Ambulatoriali, and the Italian Association for Cardiovascular Prevention, Rehabilitation and Epidemiology using e-mail addresses available from each society’s database. This initial e-mail explained the survey and the consent process and directed cardiologists to the Web site, where they could click on the SOCRATES survey and complete it. The recruitment e-mail informed the cardiologists that completing the Web-based survey implied consent to use the collected data, that the collected data would be stored in an encrypted and secure database, and that no identifying information would be collected. It was emphasized that no individual data would be used for any purpose. The survey required about 8 to 10 minutes for completion.
Cardiologists were invited to complete the survey during a 3-month period from January 17 to April 18, 2012. To enhance survey response, a reminder notice was sent to all cardiologists for a total of 7 times after the first invitation, at an interval of approximately every 10 to 14 days, providing a reminder to complete the questionnaire.
All data collected in the survey were analyzed. Demographics and subjects characteristics were described with the use of descriptive statistics. Absolute and percentage frequencies were used for qualitative variables; mean, SD, range, median, and quartiles were used to summarize quantitative variables. Principal data were also stratified by gender, age, and self-reported cardiovascular risk. SAS (SAS Institute Inc., Cary, North Carolina) was used for statistical analysis.
Results
During the 3-month period of the survey, 1,770 of the 5,240 cardiologists contacted (33.7%) completed and returned ≥1 section of the questionnaire. Most of the physicians agreeing to participate answered <24 hours after receiving the first or subsequent invitation. If there was no response within 24 hours of the e-mail, the rate of participation decreased significantly without repeated reminder e-mails. The response rate that was seen across different regions of the country was quite uniform, so that these data could be considered representative of Italian cardiologists, regardless of their locations.
Cardiologists’ demographics and professional features are listed in Table 1 . Most cardiologists were 40 to 65 years of age, with 10% aged <40 years and 4.7% aged >65 years. Women represented 1/4 of the total, but among cardiologists aged <40 years old, there were more women than men.
| Variable | Value |
|---|---|
| Women/men | 465 (26.5%)/1,288 (73.5%) |
| Mean age (yrs) | 53 |
| Age distribution (yrs) | |
| <40 | 181 (10.3%) |
| 40–65 | 1,490 (85%) |
| >65 | 83 (4.7%) |
| Gender distribution according to age | |
| Women/men, <40 yrs | 95/83 |
| Women/men, 40–65 yrs | 365/1,119 |
| Women/men, >65 yrs | 1/82 |
| Specialty | |
| Clinical cardiology | 1,316 (74.7%) |
| Cardiac/coronary catheterization | 232 (13.2%) |
| Prevention/rehabilitation | 114 (6.4%) |
| Other | 100 (5.7%) |
Table 2 lists the prevalence of cardiovascular risk and lifestyle factors. More than 20% reported histories of hypertension, and 1/3 reported hypercholesterolemia. Diabetes was relatively uncommon, whereas active smoking, a sedentary lifestyle, and stress at work were reported frequently. Most cardiologists reported eating a Mediterranean-style diet. Finally, a history of a atherosclerotic vascular events (coronary, carotid, or peripheral) was reported by 5.2% of the cardiologists in the survey.
| Risk or Lifestyle Factor | Percentage |
|---|---|
| Hypertension | 23.3 |
| Diabetes mellitus | 3.2 |
| Hypercholesterolemia | 35 |
| Smoking status | |
| Active | 12.4 |
| Previous | 27.5 |
| Family history of coronary artery disease | 13.4 |
| Previous cardiovascular events | 5.2 |
| Physical activity | |
| Minimal or none | 39.4 |
| Mild to moderate | 45.5 |
| Intense | 15.1 |
| Mediterranean diet | 83.5 |
| Stress at work | 27.3 |
| Stress at home | 14.3 |
The self-reported physical and biochemical data are listed in Table 3 . Irrespective of a history of hypertension and/or pharmacologic therapy, about 10% of participants reported arterial pressure higher than normal values; >45% were overweight or obese, and 20% of men and women had waist circumferences greater than normal. Blood analysis performed within 12 months was reported by 76% of the participants: cholesterol levels were >190 mg/dl in >50% of cardiologists, including 27% of subjects not reporting histories of hypercholesterolemia. Furthermore, 1.6% had glucose levels >126 mg/dl, despite not reporting diagnoses of diabetes. Metabolic syndrome, as defined by the National Cholesterol Education Program Adult Treatment Panel III definition, was identified in 9.3% of subjects, but its real prevalence may have been underestimated as a consequence of concomitant pharmacologic treatment for hypertension and hyperlipidemia. Finally, a mild reduction of renal function, as expressed by an estimated glomerular filtration rate <60 ml/min/1.73 m 2 , was present in 4% of the cardiologists.
| Variable | Value |
|---|---|
| Blood pressure (mm Hg) | |
| Systolic | 122 ± 11 |
| Diastolic | 77 ± 7.6 |
| Systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg | 9.7% |
| Mean body mass index (kg/m 2 ) | 24.9 ± 3.3 |
| 25–29.9 | 38.4% |
| ≥30 | 7.2% |
| Waist circumference (cm) | |
| Men | 95.0 ± 10.5 |
| Women | 79.1 ± 11.2 |
| >102 cm (men) | 19.9% |
| >88 cm (women) | 20% |
| Total cholesterol (mg/dl) | 197.6 ± 34.8 |
| >190 mg/dl | 54.5% |
| Subjects with total cholesterol >190 mg/dl and without known hypercholesterolemia | 27% |
| Low-density lipoprotein cholesterol (mg/dl) | 115 ± 31 |
| High-density lipoprotein cholesterol (mg/dl) | 53.6 ± 11.5 |
| <40 (men) | 9.9% |
| <45 (women) | 10.3% |
| Triglycerides (mg/dl) | 122 ± 47 |
| Fasting blood glucose (mg/dl) | 92 ± 13 |
| Subjects with fasting blood glucose >126 mg/dl without known diabetes | 0.4% |
| Prevalence of metabolic syndrome (Adult Treatment Panel III definition) ∗ | 9.3% |
| Creatinine (mg/dl) | 0.9 ± 0.3 |
| Estimated glomerular filtration rate (Chronic Kidney Disease Epidemiology Collaboration method) (ml/min) | 88.5 ± 17 |
| <60 ml/min/1.73 m 2 | 4% |
∗ Prevalence of the metabolic syndrome may have been underestimated because of concomitant drug therapy acting on lipid fractions and blood pressure.
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