Italian Digital Primary Cardiovascular Prevention Study

CV-PREVITAL is an RCT investigating whether an mHealth application (App) provided on top of usual care, can improve lifestyle habits and CV risk factor control in the short-term, and the incidence of major CV events in the long- term. Participants undergo two clinical visits, the first at baseline and the second after 12 months. During these visits, total cholesterol, HDL, LDL, triglyceride, HbA1c, blood pressure, heart rate, BMI and waist circumference are measured. In addition, using questionnaires provided digitally, participants self-report data on the following topics: adherence to the Mediterranean diet, salt intake, alcohol consumption, physical activity, current and previous smoking history, psychosocial profile, and sleep quality. Demographic information, including education, socio-economic status and ethnic origin are also obtained at baseline. Subjects in the intervention group also receive the credentials to download the App, which contains educational information on cardiovascular risk factors, diet, physical activity, lifestyle and psycho-behavioral aspects. Using ad hoc designed algorithms, the App delivers personalized prevention programs based on periodic messages providing advice, motivational reminders and support to improve lifestyle and risk factor control. When at baseline high levels of blood pressure, blood glucose or cholesterol are detected, the App support the participant in self-monitoring the clinical changes of such variables during the follow up. The efficacy of the intervention is evaluated at the12th month using a cardiovascular risk score developed ad hoc in an Italian population (Modified Moli-Sani Score). The ability of the intervention to maintain its effect over time and its effectiveness in improving clinical outcomes are assessed at the 7th year of follow-up. The cost-effectiveness of the intervention is also evaluated at the 7th year.

The study envisages the recruitment of 82,800 participants (aged ≥45y) nationwide. Of these, 50,000 are selected among those who daily access the GPs ambulatories associated to the Co.S. consortium. In order to assess whether the scheduled mHealth intervention can be effective also in settings different from the primary care, several specific cohorts in primary prevention are also enrolled by specialized units belonging to Scientific Institutes for Research, Hospitalization and Health Care (Italian acronym IRCCS). These cohorts include 32,800 subjects in total. Specifically, the UO-1 (IRCCS Cardiologico Monzino in Milan) enrolls 5,000 participants selected among citizens attending to community pharmacies; the UO-2 (IRCCS Auxologico in Milan) enrolls 5,000 subjects, 1,500 of which belonging to the Centre for Sleep Medicine; the UO-3 (IRCCS Humanitas in Milan) enrolls 2,000 subjects attending the institution; the UO-4 (IRCCS Mario Negri in Milan) does not recruit any subject but provides scientific and organizational support for the enrolment carried out by Co.S.; the UO-5 (IRCCS MultiMedica in Milan) enrolls 1,000 subjects with diabetes and 2,000 subjects from the general population; the UO-6 (IRCCS Neuromed in Pozzilli) enrols 10,000 subjects from the Neuromed clinical research centres; the UO-7 (IRCCS San Donato in Milan) enrolls 1,000 subjects selected among its own employees; the UO-8 (IRCCS Maugeri in Pavia) enrolls 1,000 subjects selected among its own employees; the UO-9 (IRCCS ISMETT, Mediterranean Institute for Transplantation and Advanced Specialized Therapies, in Palermo) enrolls 150 subjects who undergoes a physical activity program; the UO-10 (IRCCS San Martino in Genoa) enrolls 2,000 male subjects from the Municipality of Genoa; the UO-11 (IRCCS Ca' Granda of Milan) enrolls 2,000 blood donors afferent to its own Department of Transfusion Medicine and Hematology (DMTE); the UO-12 (IRCCS Gemelli in Rome) enrolls 1,000 subjects attending to the outpatient clinics of the Non-Invasive Cardiology Diagnostic Unit, of the Centre for Hypertension, and of the Centre for Endocrine and Metabolic Diseases; the UO-13 (IRCCS San Matteo in Pavia) enrolls 500 subjects selected among asymptomatic relatives of patients attending to the Policlinico San Matteo for cardiology reasons; the UO-14 (IRCCS San Raffaele in Rome) enrolls 150 subjects selected among its own employees.

Baseline data of the 82,800 participants and 1- and 7-years outcomes are also used to develop and validate a new algorithm for cardiovascular risk estimation. The new algorithm is developed by identifying among alcohol intake (as assessed by PREDIMED questionnaire), salt intake (as assessed by MiniSal questionnaire), perceived stress (as assessed by perceived stress scale (PSS), anxiety and depression (as assessed by Patient Health Questionnaire 4; PHQ 4), Locus of control (as assessed by Multidimensional Health Locus of Control scale, MHLCS), General Self Efficacy (as assessed by General Self Efficacy Scale; GSE), Risk propensity (as assessed by Risk Propensity Scale; RPS), and sleep quality (as assessed by Pittsburgh Sleep Quality Index) those variables that significantly improve the predictive power of the modified Moli-Sani algorithm.

The CV-PREVITAL trial also envisages a series of ancillary studies that are conducted by the various IRCCSs on the subjects already participating in the main study. Each ancillary study has its own protocol and aims, and foresees the evaluation of the role of further biomarkers relevant in the assessment of cardiovascular risk. The sub-study aims, outcomes information and time frame are described below. Baseline data of many ancillary studies are used to identify conventional and emerging determinants of specific cardiometabolic diseases. Specifically: a) the IRCCS Monzino analyses with multivariable approaches determinants and factors predisposing to diabetes status as assessed by Framingham diabetes score; b) the IRCCS Auxologico will apply additional elements for risk stratification including biomarkers high sensitive C-reactive protein (hs-CRP), Troponin I, N-terminal pro-brain natriuretic peptide (NT-proBNP), as well as 24 h ABPM (Ambulatory Blood Pressure Monitoring) derived variables; c) the IRCCS Humanitas analyses the frequency of genetic polymorphisms related to severe coronary calcification of its own cohort to identify genetic determinants of severe coronary calcification; d) the IRCCS MultiMedica analyses with multivariable approaches anthropometric (e.g. weight, height, BMI), biochemical data (e.g. lipid profile) and specific genetic disorders (e.g. presence of causative mutations in known genes involved in dyslipidemia) to identify determinants predisposing to dyslipidemia, hypertension and diabetes; e) the IRCCS Neuromed analyses with multivariable approaches determinants of dietary changes in the CV-PREVITAL Neuromed sub-study cohort; f) the Istituti Clinici Scientifici Maugeri IRCCS analyses baseline data of its own cohort with multivariable approaches to identify determinants of organ damage such as coronary silent ischemia, ankle brachial index, coronary calcium score and carotid ultrasound as well as Genetic and epigenetic (DNA and RNA) and other chemical determinants and factors predisposing to atherosclerotic diseases; g) the IRCCS Ca' Granda performs a 7 years validation of new monogenic and polygenic cardiovascular risk scores in its own primary prevention cohort. To this aim the study cohort is genotyped with GWAS and Whole Exome Sequencing (WES) for genetic factors influencing intracellular lipid handling (PNPLA3 I148M, TM6SF2 E167K, GCKR P446L, MBOAT7). Epigenetic variables indicated in the literature as early predictors of cardiovascular injury and cardiovascular events are also investigated. In addition to the characterization of genetic variants in known associated genes, the genomic characterization will allow the validation of candidate risk variants in genes reported to influence cardiovascular damage, the identification of potentially new candidate variants, and the calculation of polygenic cardiovascular risk scores and of their possible application to disease risk stratification in the Italian population; h) the IRCCS San Matteo develops new monogenic and polygenic scores and validates existing scores for the risk assessment of developing diabetes, hypertension and hypercholesterolemia.

Beyond the specific aims of the single sub-studies, a relevant goal common to all sub-studies is the collection of biological samples for the multisite biobank of the ICN.

The full list of approving body and approval number/ID of CV-PREVITAL studies is reported below.

Parent study: Approval Number: R1256/20-CCM 1319; Board Name: Comitato Etico degli IRCCS Istituto Europeo di Oncologia e Centro Cardiologico Monzino.

Ancillary studies of Monzino: Approval Number: R1579/21-CCM 1677 and R1617/22-CCM 1723; Board Name: Comitato Etico degli IRCCS Istituto Europeo di Oncologia e Centro Cardiologico Monzino.

Ancillary study of Istituto Auxologico Italiano: Approval Number: 2022_03_08_06; Board Name: Comitato Etico dell'IRCCS Istituto Auxologico Italiano.

Ancillary study of Humanitas: Approval Number: 2860; Board Name: Comitato Etico Indipendente dell'Istituto Clinico Humanitas.

Ancillary study of Multimedica: Approval Number: MM: 472.2021; Board Name: Comitato Etico IRCCS Multimedica - Sezione del Comitato Etico Centrale IRCCS Lombardia.

Ancillary study of Neuromed: Approval: Session of 28/09/2020; Board Name: Comitato Etico dell'Istituto Neurologico Mediterraneo Neuromed.

Ancillary study of San Donato: Approval Number: 197/INT/2021; Board Name: Comitato Etico IRCCS Ospedale San Raffaele.

Ancillary study of Maugeri: Approval Number: 2575 CE; Board Name: Comitato Etico degli Istituti Clinici Scientifici Maugeri.

Ancillary study of ISMETT: Approval Number: IRRB/16/22; Board Name: Comitato Etico IRCCS Sicilia.

Ancillary study of San Martino: Approval Number: 173/2021; Board Name: Comitato Etico Regionale della Liguria.

Ancillary study of Ca' Granda: Approval Number: 887_2020; Board Name: Comitato Etico Milano Area 2.

Ancillary study of Gemelli: Approval Number: 3614; Board Name: Comitato Etico della Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore.

Ancillary study of San Matteo: Approval Number: 2022-3.11/91 and 2022-3.11/493; Board Name: Comitato Etico Pavia.

Ancillary studiy of San Raffaele Roma: Approval Number: 21/21; Board Name: Comitato Etico IRCCS San Raffale Roma.

Update on Study Progress and Power Analysis: In its original design, the CV-PREVITAL study aimed to enrol approximately 80,000 subjects aged ≥45 years with no previous cardiovascular events. These participants were intended to be recruited from general practice clinics, pharmacies, or clinics of Scientific Institutes for Research, Hospitalization and Health Care (IRCCS). However, due to the challenges posed by the COVID-19 pandemic, which has fully engaged all parties involved in the study (primarily general practitioners, pharmacists, and IRCCS physicians), the planned activities of the study have been significantly delayed, especially in terms of participant enrollment. Despite these challenges, the study successfully recruited around 28,000 subjects, which is expected to be a sufficient number for evaluating the short-term primary endpoint. Specifically, to assess the short-term primary endpoint, a sample size of N=7895 per treatment arm is required, assuming a significance level of 0.05 and a power of 90%. Therefore, if the target of 16,000 subjects with completed follow-up is achieved, the study will have adequate power to reach the short-term primary endpoint. The estimation of the statistical power for the long-term endpoint will be carried out at the conclusion of the 7-year follow-up period when data regarding the actual dropout rate become available.