The cross-sectional design included all individuals aged 35–74 years attended in the primary care centers of the Catalan Institute of Health from January 2006 through December 2009. The study was conducted in Catalonia, a Mediterranean region in northeastern Spain. The protocol of study has been explained elsewhere.8

Briefly, within Spain's National Health System that serves every citizen, the Catalan Institute of Health administers a network of 279 primary care centers that serves approximately 80% of the Catalan population. Each individual is registered with a primary care team (general practitioner and nurse) in one of these publicly funded centers. As the main health provider for Catalonia, this network employs about 3500 primary care physicians and serves 5.8million patients.12

The protocol of the present study was approved by the primary care research arm of the Catalan Institute of Health, the Institut d’Investigació en Atenció Primària Jordi Gol Clinical Research Ethics Committee (authorization number P09/28).

All personal identifiers were eliminated before EMR data were pooled and queried for patients seen between 2006 and 2009. The database contained the most recent information for each patient: age, sex, and the International Classification of Diseases (ICD) codes for hypertension, hypercholesterolemia, DM2, coronary heart disease, stroke, and peripheral artery disease. If available, values and dates for measurements of systolic and diastolic blood pressure, total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides, glycemia, and glycated hemoglobin, along with information regarding smoking cessation, if applicable.

The Framingham risk score validated for Spain by the Girona Heart Registry researchers (Framingham-REGICOR)13 was calculated for records containing complete data (age, sex, DM2, systolic and diastolic blood pressure, total cholesterol, and HDL cholesterol) and no history of CVD. Using Framingham-REGICOR risk charts, a cut-off point of 10% was used as the indicator for hypercholesterolemia drug treatment.14

Hypertension, diabetes, and hypercholesterolemia were identified when diagnosis or treatment for these disorders was recorded between 2006 and 2009. These subsamples of participants were used for estimating the proportion of controlled patients for each disease. Optimal control of hypertension was considered if a record included a systolic blood pressure <140mmHg and diastolic blood pressure <90mmHg after diagnosis or treatment. Optimal control, suboptimal control, and uncontrolled diabetes was considered if an individual already diagnosed or treated presented with glycated hemoglobin <7%, ≥7% and <8% or ≥8%, respectively. Optimal control of hypercholesterolemia was considered when LDL-cholesterol was <100mg/dl in patients with CVD history or <130mg/dl in those with no CVD history and coronary risk ≥10% or cholesterol-lowering drug treatment.

The most common groups of medications were considered: antihypertensive agents (diuretics, angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, calcium channel blockers, angiotensin II receptor antagonists (ARA-II), alpha-blockers, central nervous system sympatholytics, and direct acting vasodilators); hypoglycemic agents (biguanide, sulfonylurea, alpha-glucosidase inhibitor, thiazolidinedione, dipeptidyl peptidase-4 inhibitors, other oral hypoglycemic agents and insulin); and lipid-lowering drugs (statins, fibrates, ion exchange resins, ezetimibes, other lipid-lowering agents). Within each disorder, we also described the percentage of individuals treated with the most common combinations of drugs.

Prevalence is presented by sex and is standardized to the age distribution of the European population.15 Continuous variables are presented as mean and 95% confidence interval (CI), and categorical variables as proportions and 95%CI.

Missing values for 8 variables (smoking, total, LDL and HDL cholesterol, triglycerides, glucose, and systolic and diastolic blood pressure) were imputed from multivariate linear models of every missing variable as a function of sex, age, and the rest of variables fitted by the multiple imputation method.

Student T test was used to compare means of continuous variables and Chi-squared for proportions.

The R Statistical Package (R Foundation for Statistical Computing, Vienna, Austria; Version 2.15.0) and STATA software, version 12 (Stata Corp., College Station, TX, USA) were used for data analysis.

The estimated prevalence of hypertension and diabetes diagnosis and treatment in our study was similar to that observed in previous nationwide epidemiological studies.9,10,20 However, comparisons for hypercholesterolemia are difficult because different thresholds are used to diagnose or treat this disorder.9,10,21,22

The outstanding mean value of HDL cholesterol in Catalan women (60mg/dl) concurs with the DARIOS Study results.10 This protective factor may be related to the low incidence of myocardial infarction observed in the female population in South Europe,23,24 and should considered in the design and implementation of prevention strategies in the region. Finally, CVD risk should be estimated with instruments validated for the population.25

Notably, treatment profiles for all three disorders studied followed the recommendations described in the most updated, evidence-based, clinical practice guidelines.16–18 These guidelines (accessible via the EMR system) standardize procedures, reduce unjustified variations in clinical practice, and encourage physician behavior that promotes interventions supported by the best evidence available.26,27 However, the low control of hypercholesterolemia, as measured with LDL cholesterol, must be highlighted. Despite statin therapy in 90% of individuals diagnosed with hypercholesterolemia, less than one third of individuals requiring primary prevention of CVD had LDL-cholesterol <130mg/dl. These results were only slightly better when we calculated the proportion of individuals with history of CVD and LDL-cholesterol below the recommended threshold (<100mg/dl). Indeed, the 2004 LIPICAP Study, which included primary care patients diagnosed with hypercholesterolemia, reports similar results.28

On the other hand, the control of hypertension and diabetes was higher than that previously reported and could reflect the implementation of more efficient strategies of controlling cardiovascular risk factors in primary care settings.29,30 In our study, diuretics and ACE inhibitors were the most used antihypertensive agents, as recommended in clinical practice guidelines.16 However, ARA-II was the most frequently prescribed in the PRESCAP 2006 Study.29 In addition, the proportion of women with controlled hypertension was higher than in men. These results concurred with those observed in previous Spanish population-based studies.10,31 The high proportion of individuals controlled and treated with just one drug for hypertension compared with previous studies could be due to the age of the participants included (i.e., up to 74 years).32 On the other hand, biguanide and sulfonylurea were the most frequently used drugs in our study for managing DM2. The UKPDS study highlighted the effects of both drugs for controlling glucose levels.33 In addition, more than 40% of individuals with diabetes were treated with 2 or more drugs, concurring with eControl study results in Catalonia, which included almost 290,000 individuals with diabetes mellitus aged 30–89 years,34 and with the SFIDA study conducted in Italy.35

Computerization of primary care EMRs has made available large volumes of routinely collected data. Integrating clinical decision support systems (e.g., electronic clinical practice guidelines) in EMR should improve clinical outcomes, patient safety, particularly important for improving the management of chronic diseases.36 In addition, avoid duplication of tests, audit the effectiveness of care and finally provide data for research.37 Indeed, an increasing number of studies have used EMR databases to assess the prevalence and control of cardiovascular risk factors.6,38–40

The results of these studies may help to improve both the pharmacological and non-pharmacological interventions recommended for CVD prevention. The objective is to increase the opportunities to avert or at least slow down the clinical expression of atherosclerosis in the general population. New knowledge may help to produce evidence-based documents to guide health professionals’ actions. Indeed, the most recently released clinical practice guidelines for all three disorders described in the present study (hypercholesterolemia, hypertension and diabetes) have been integrated with our EMR system.16–18

The present study was conducted in primary care settings in Catalonia. The sample represents 59% of the total population of this area (and 78% of those attending Catalan Health Institute primary care centers), aged 35–74 years. Older individuals were excluded from analysis because we aimed to know the mean cardiovascular risk of the population, which cannot be estimated by Framingham REGICOR in those older than 75 years. On the one hand, individuals attended in primary care could have more pathologies than the non-attended population. However, the universal coverage of our public health system minimizes these differences. On the other hand, the differences between studies in the observed prevalences, estimated using the recorded diagnosis or diagnosis and treatment, may reflect some problems in the quality of the records used. However, in our case the previous validation of this database minimizes potential problems related to underreported data.6,41 In addition, high-quality reporting is key not only to ensure better quality of care for patients but also to improve databases that could have great potential for epidemiological studies and population comparisons. Further studies are planned for analyzing the treatments for hypertension, diabetes mellitus type 2 and hypercholesterolemia in depth.

In conclusion, hypertension was the most common cardiovascular risk factor in the Catalan population aged 35–74 years, followed by hypercholesterolemia and diabetes. Diuretics and ACE inhibitors were the most common drugs used to treat hypertension; biguanides and statins were most often used for treating diabetes and hypercholesterolemia, respectively. Good control was achieved in approximately two thirds of hypertensive patients (68% of women and 66% of men), as well as two thirds of women and more than half of men diagnosed with diabetes (65% and 59%); however, closer to one third of patients, with and without history of CVD, had adequately controlled hypercholesterolemia.