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  • 1.
    Hellgren, Mikko
    et al.
    University Health Care Research Centre, Örebro University Hospital, Örebro, Sweden; School of Medical Sciences, Örebro University, Örebro, Sweden.
    Wennberg, Patrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Hedin, Katarina
    Futurum, Region Jönköping County, Jönköping, Sweden; Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden.
    Jansson, Stefan
    University Health Care Research Centre, Örebro University Hospital, Örebro, Sweden; School of Medical Sciences, Örebro University, Örebro, Sweden; Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden.
    Nilsson, Staffan
    Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
    Nilsson, Gunnar
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Wändell, Per
    Department of Neurobiology, Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Huddinge, Sweden.
    Bengtsson Boström, Kristina
    School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden.
    Hypertension management in primary health care: a survey in eight regions of Sweden2023In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 41, no 3, p. 343-350Article in journal (Refereed)
    Abstract [en]

    Purpose: To explore hypertension management in primary healthcare (PHC).

    Design: Structured interviews of randomly selected PHC centres (PHCCs) from December 2019 to January 2021.

    Setting: Seventy-six PHCCs in eight regions of Sweden.

    Main outcome measures: Staffing and organization of hypertension care. Methods of measuring blood pressure (BP), laboratory tests, registration of co-morbidities and lifestyle advice at diagnosis and follow-up.

    Results: The management of hypertension varied among PHCCs. At diagnosis, most PHCCs (75%) used the sitting position at measurements, and only 13% routinely measured standing BP. One in three (33%) PHCCs never used home BP measurements and 25% only used manual measurements. The frequencies of laboratory analyses at diagnosis were similar in the PHCCs. At follow-up, fewer analyses were performed and the tests of lipids and microalbuminuria decreased from 95% to 45% (p < 0.001) and 61% to 43% (p = 0.001), respectively. Only one out of 76 PHCCs did not measure kidney function at routine follow-ups. Lifestyle, physical activity, food habits, smoking and alcohol use were assessed in ≥96% of patients at diagnosis. At follow-up, however, there were fewer assessments. Half of the PHCCs reported dedicated teams for hypertension, 82% of which were managed by nurses. There was a great inequality in the number of patients per tenured GP in the PHCCs (median 2500; range 1300–11300) patients.

    Conclusions: The management of hypertension varies in many respects between PHCCs in Sweden. This might lead to inequity in the care of patients with hypertension.

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  • 2.
    Nilsson, Gunnar
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Ischaemic heart disease - risk assessment, diagnosis, and secondary preventive treatment in primary care: with special reference to the relevance of exercise ECG2016Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background: Ischaemic heart disease is a diagnostic and therapeutic challenge to most general practitioners. We sought to identify diagnostic characteristics and prognoses of patients in primary care that received exercise electrocardiography (ECG). We compared the ECG test results with respect to probability of subsequent cardiologist referrals. We also aimed to identify determinants for pre-hospital delays and lack of statin treatment before a first-time myocardial infarction (MI).

    Methods: Setting: Region of Jämtland Härjedalen, Sweden (adult population, approximately 99 000); study period 2010-2014. Patients and study designs: studies I and II: 865 patients referred to exercise ECG. Primary outcome: Incidence of cardiovascular events (I) and cardiologist referrals within six months after exercise ECG (II). Observed outcomes were compared to predictions from multivariable logistic models. Study III: 265 patients with first-time MI. Characteristics were analysed for determinants of pre-hospital delay ≥ 2 hours. Study IV: Survey of 931 patients with first-time MI. Analyses of characteristics associated with rates of statin treatment in patients with previously diagnosed cardiovascular diseases (CVD).

    Results: Study I: Exercise test results were associated with exertional chest pain, a pathologic ST-T segment on resting ECG, angina diagnosis according to the patient's opinion, and medication for dyslipidaemia. Cardiovascular events occurred in 52.7%, 18.3%, and 2.0% of patients with positive (ST-segment depression >1mm and chest pain indicative of angina), inconclusive (ST depression or chest pain), or negative tests, respectively. Study II: Positive or inconclusive exercise tests were associated with cardiologist referrals. Among patients with positive exercise tests, referral rates decreased with age, after adjusting for co-morbidity. Self-employed women were referred to cardiologic evaluations more often than other employed women. Study III: The first medical contact was a primary care facility for 52.3% of patients. The pre-hospital delay time was ≥ 2 h for 67.0% of patients in primary care and 44.7% of patients that called emergency medical services or were self-referred to hospital. Study IV: Among patients with prior CVD, 34.5% received current statin treatment before for the first MI. Statin treatment rates decreased with age, after adjusting for CVD and diabetes; women ≥70 years old were treated half as often as men of the same age.

    Conclusions: Clinical characteristics can be used to identify patients at low risk of cardiac events. The prognosis in patients with a negative exercise ECG was benign for six months after the exercise ECG. Exercise tests are important for selecting patients that require cardiologic evaluations. Age, gender, and employment status interacted with rates of referrals for cardiac evaluation. The pre-hospital delay time was considerably prolonged, particularly when primary care was the first medical contact. Only one third of patients with a prior CVD received statin treatment. Pre-MI statin treatment decreased with age, particularly among women ≥70 years old. In making medical decisions, it is necessary to be aware of biases regarding age, gender, and socioeconomic status. Methodologies for case finding and follow-up need to be improved and implemented in clinical practice.

    Keywords: Exercise ECG, Ischaemic heart disease, Myocardial infarction, Pre-hospital delay, Primary care, Prognosis, Referral, Statins, Secondary prevention

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  • 3.
    Nilsson, Gunnar
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Kön och ålder påverkar remittering till kranskärlsutredning2015In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 112, no 6, article id DCHZArticle in journal (Other academic)
  • 4.
    Nilsson, Gunnar
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Ålder och kön påverkade behandling vid hjärt–kärlsjukdom2016In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 113, no 14, article id DYZ6Article in journal (Other academic)
  • 5.
    Nilsson, Gunnar
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Lindam, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    A comparative trial of blood pressure monitoring in a self-care kiosk, in office, and with ambulatory blood pressure monitoring2024In: BMC Cardiovascular Disorders, E-ISSN 1471-2261, Vol. 24, no 1, article id 27Article in journal (Refereed)
    Abstract [en]

    Background: Automated measurement of blood pressure (BP) in designated BP kiosks have in recent years been introduced in primary care. If kiosk blood pressure (BP) monitoring provides results equivalent to in-office BP or daytime ambulatory BP monitoring (ABPM), follow-up of adult patients could be managed primarily by self-checks. We therefore designed a comparative trial and evaluated the diagnostic performance of kiosk- and office-based BP (nurse- versus physician-measured) compared with daytime ABPM.

    Methods: A trial of automated BP monitoring in three settings: a designated BP kiosk, by nurses and physicians in clinic, and by ABPM. The primary outcome was systolic and diastolic BP, with respective diagnostic thresholds of ≥135 mmHg and/or ≥ 85 mmHg for daytime ABPM and kiosk BP and ≥ 140 mmHg and/or ≥ 90 mmHg for office BP (nurse- and physician-measured).

    Results: Compared with daytime ABPM, mean systolic kiosk BP was higher by 6.2 mmHg (95% confidence interval [CI] 3.8–8.6) and diastolic by 7.9 mmHg (95% CI 6.2–9.6; p < 0.001). Mean systolic BP taken by nurses was similar to daytime ABPM values (+ 2.0 mmHg; 95% CI − 0.2–4.2; p = 0.071), but nurse-measured diastolic values were higher, by 7.2 mmHg (95% CI 5.9–9.6; p < 0.001). Mean systolic and diastolic physician-measured BPs were higher compared with daytime ABPM (systolic, by 7.6 mmHg [95% CI 4.5–10.2] and diastolic by 5.8 mmHg [95% CI 4.1–7.6]; p < 0.001). Receiver operating characteristic curves of BP monitoring across pairs of systolic/diastolic cut-off levels among the three settings, with daytime ABPM as reference, demonstrated overall similar diagnostic performance between kiosk and nurse-measured values and over the curve performance for physician-measured BP. Accuracy with nurse-measured BP was 69.2% (95% CI 60.0–77.4%), compared with 65.8% (95% CI 56.5–74.3%) for kiosk BP.

    Conclusions: In this study kiosk BP monitoring was not comparable to daytime ABPM but could be an alternative to in-office BP monitoring by trained nurses. The diagnostic performance of kiosk and nurse-measured BP monitoring was similar and better than that of physician-measured BP.

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  • 6.
    Nilsson, Gunnar
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine. Unit Clin Res Ctr Östersund, Umeå, Sweden.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Diagnostic characteristics and prognoses of primary-care patients referred for clinical exercise testing: a prospective observational study2014In: BMC Family Practice, E-ISSN 1471-2296, Vol. 15, article id 71Article in journal (Refereed)
    Abstract [en]

    Background: Evaluation of angina symptoms in primary care often includes clinical exercise testing. We sought to identify clinical characteristics that predicted the outcome of exercise testing and to describe the occurrence of cardiovascular events during follow-up. Methods: This study followed patients referred to exercise testing for suspected coronary disease by general practitioners in the County of Jamtland, Sweden (enrolment, 25 months from February 2010). Patient characteristics were registered by pre-test questionnaire. Exercise tests were performed with a bicycle ergometer, a 12-lead electrocardiogram, and validated scales for scoring angina symptoms. Exercise tests were classified as positive (ST-segment depression > 1 mm and chest pain indicative of angina), non-conclusive (ST depression or chest pain), or negative. Odds ratios (ORs) for exercise-test outcome were calculated with a bivariate logistic model adjusted for age, sex, systolic blood pressure, and previous cardiovascular events. Cardiovascular events (unstable angina, myocardial infarctions, decisions on revascularization, cardiovascular death, and recurrent angina in primary care) were recorded within six months. A probability cut-off of 10% was used to detect cardiovascular events in relation to the predicted test outcome. Results: We enrolled 865 patients (mean age 63.5 years, 50.6% men); 6.4% of patients had a positive test, 75.5% were negative, 16.4% were non-conclusive, and 1.7% were not assessable. Positive or non-conclusive test results were predicted by exertional chest pain (OR 2.46, 95% confidence interval (Cl) 1.69-3.59), a pathologic ST-T segment on resting electrocardiogram (OR 2.29, 95% Cl 1.44-3.63), angina according to the patient (OR 1.70, 95% Cl 1.13-2.55), and medication for dyslipidaemia (OR 1.51, 95% CI 1.02-2.23). During follow-up, cardiovascular events occurred in 8% of all patients and 4% were referred to revascularization. Cardiovascular events occurred in 52.7%, 18.3%, and 2% of patients with positive, non-conclusive, or negative tests, respectively. The model predicted 67/69 patients with a cardiovascular event. Conclusions: Clinical characteristics can be used to predict exercise test outcome. Primary care patients with a negative exercise test have a very low risk of cardiovascular events, within six months. A predictive model based on clinical characteristics can be used to refine the identification of low-risk patients.

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  • 7.
    Nilsson, Gunnar
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Söderström, Lars
    Region Jämtland Härjedalen.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Pre-hospital delay in patients with first time myocardial infarction: an observational study in a northern Swedish population2016In: BMC Cardiovascular Disorders, ISSN 1471-2261, E-ISSN 1471-2261, Vol. 16, no 1, article id 93Article in journal (Refereed)
    Abstract [en]

    Background: In myocardial infarction (MI), pre-hospital delay is associated with increased mortality and decreased possibility of revascularisation. We assessed pre-hospital delay in patients with first time MI in a northern Swedish population and identified determinants of a pre-hospital delay ≥2 h.

    Methods: A total of 89 women (mean age 72.6 years) and 176 men (mean age 65.8 years) from a secondary prevention study were enrolled in an observational study after first time MI between November 2009 and March 2012. Total pre-hospital delay was defined as the time from the onset of symptoms suggestive of MI to admission to the hospital. Decision time was defined as the time from the onset of symptoms until the call to Emergency Medical Services (EMS). The time of symptom onset was assessed during the episode of care, and the time of call to EMS and admission to the hospital was based on recorded data. The first medical contact was determined from a mailed questionnaire. Determinants associated with pre-hospital delay ≥ 2 h were identified by multivariable logistic regression.

    Results: The median total pre-hospital delay was 5.1 h (IQR 18.1), decision time 3.1 h (IQR 10.4), and transport time 1.2 h (IQR 1.0). The first medical contact was to primary care in 52.3 % of cases (22.3 % as a visit to a general practitioner and 30 % by telephone counselling), 37.3 % called the EMS, and 10.4 % self-referred to the hospital. Determinants of a pre-hospital delay ≥ 2 h were a visit to a general practitioner (OR 10.77, 95 % CI 2.39–48.59), call to primary care telephone counselling (OR 3.82, 95 % CI 1.68–8.68), chest pain as the predominant presenting symptom (OR 0.24, 95 % CI 0.08–0.77), and distance from the hospital (OR 1.03, 95 % CI 1.02–1.04). Among patients with primary care as the first medical contact, 67.0 % had a decision time ≥ 2 h, compared to 44.7 % of patients who called EMS or self-referred (p = 0.002).

    Conclusions: Pre-hospital delay in patients with first time MI is prolonged considerably, particularly when primary care is the first medical contact. Actions to shorten decision time and increase the use of EMS are still necessary.

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  • 8.
    Nilsson, Gunnar
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine. Unit of Research, Education and Development, Östersund Hospital, Östersund, Sweden.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Söderström, Lars
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Use of exercise tests in primary care: importance for referral decisions and possible bias in the decision process; a prospective observational study2014In: BMC Family Practice, E-ISSN 1471-2296, Vol. 15, article id 182Article in journal (Refereed)
    Abstract [en]

    Background: The utility of clinical exercise tests depends on their support of treatment decisions. We sought to assess the utility of exercise tests for the selection of primary-care patients for referral to cardiologic care, and to determine whether referral decisions were biased by gender or socioeconomic status. We also evaluated referral rates and cardiovascular events in patients with positive exercise tests. 

    Methods: We designed a prospective observational study of 438 men and 427 women from 28 Swedish primary-care clinics who were examined with exercise testing for suspected coronary disease. All participants were followed-up with respect to cardiologist referrals and cardiovascular events (hospitalisation for unstable angina, myocardial infarction, and cardiovascular death) within six months and revascularisation within 250 days. Variables associated with referral were identified by multivariable logistic regression. Socioeconomic status was determined by educational level and employment. 

    Results: Positive/inconclusive exercise tests and exertional chest pain predicted referral in men and women. Of 865 participants, patients with positive, inconclusive, or negative exercise tests were referred to cardiologists in 67.3%, 26.1%, and 3.5% of cases, respectively. Overall, there was no significant difference in referral rates related to gender or socioeconomic level. Self-employed women were referred more frequently compared to other women (odds ratio (OR) 3.62, 95% confidence interval (CI) 1.19-10.99). Among non-manual employees, women were referred to cardiologic examination less frequently than men (OR 0.40, 95% CI 0.16-1.00; p = 0.049; ORs adjusted for age, exertional chest pain, and exercise test result). In patients with positive exercise tests, the referral rate decreased continuously with age (OR 0.48, 95% CI 0.23-0.97; adjusted for cardiovascular co-morbidity). Cardiovascular events occurred in 22.2% (4/18) of non-referred patients with positive exercise tests; 56% (10/18) of these patients were not considered for cardiologic care, with continuity problems in primary care as one possible contributing cause. 

    Conclusions: Exercise tests are important for selecting patients for referral to cardiologic care. Interactions related to gender and socioeconomic status affected referral rates. In patients with positive exercise tests, referral rates decreased with age. An increased awareness of possible bias regarding age, gender, and socioeconomic status, which may influence medical decisions, is therefore necessary.

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  • 9.
    Nilsson, Gunnar
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Söderstrom, Lars
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Low use of statins for secondary prevention in primary care: a survey in a northern Swedish population2016In: BMC Family Practice, E-ISSN 1471-2296, Vol. 17, article id 110Article in journal (Refereed)
    Abstract [en]

    Background: Cholesterol-lowering therapy with statins is recommended in established cardiovascular disease (CVD) and should be considered for patients at high cardiovascular risk. We surveyed statin treatment before first-time myocardial infarction in clinical practice compared to current guidelines, in patients with and without known CVD in primary care clinics with general practitioners (GPs) on short-term contracts vs. permanent staff GPs. Methods: A total of 931 patients (345 women) in northern Sweden were enrolled in the study between November 2009 and December 2014 and stratified by prior CVD, comprising angina pectoris, revascularisation, ischaemic stroke or transitory ischaemic attack, or peripheral artery disease. Primary care clinics were classified by the proportion of GP salaries that were paid to GPs working on short-term contracts: low (0-9 %), medium (10-39 %), or high (>= 40 %). We used logistic regression to identify determinants of statin treatment. Results: Among patients with prior CVD, only 34.5 % received statin treatment before myocardial infarction. The probability of statin treatment decreased with age (>= 70 years OR 0.30; 95 % CI 0.13-0.66) and female gender (OR 0.39; 95 % CI 0.20-0.78) but increased in patients with diabetes (OR 3.52; 95 % CI 1.75-7.08). Among patients with prior CVD, the type of primary care clinic was not predictive of statin treatment. In the entire study cohort, 17.3 % of patients were treated with statins; women < 70 years old were more likely to receive statin treatment than women >= 70 years old (OR 3.24; 95 % CI 1.64-6.38), and men >= 70 years old were twice as likely to be treated with statins than women of the same age (OR 2.22; 95 % CI 1.31-3.76) after adjusting for diabetes and CVD. Overall, patients from clinics with predominantly permanent staff GPs received statin therapy less frequently than those with GPs on short-term contracts. Conclusions: In patients with prior CVD we found considerable under-treatment with statins, especially among women and the elderly. Methodologies for case findings, recall, and follow-up need to be improved and implemented to reach the goals for CVD prevention in clinical practice.

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  • 10.
    Nilsson, Gunnar
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Söderström, Lars
    Region Jämtland Härjedalen.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Treatment with statins prior to first time myocardial infarction, with special reference to patients with previously diagnosed cardiovascular disease: a population-based surveyManuscript (preprint) (Other academic)
  • 11.
    Nilsson, Gunnar
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Soderstrom, L.
    Alverlind, K.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Hand-held cardiac ultrasound examinations performed in primary care patients by nonexperts to identify reduced ejection fraction2019In: BMC Medical Education, E-ISSN 1472-6920, Vol. 19, article id 282Article in journal (Refereed)
    Abstract [en]

    BackgroundEarly identification of patients with reduced left ventricular ejection fraction (LVEF) could facilitate the care of patients with suspected heart failure (HF). We examined if (1) focused cardiac ultrasound (FCU) performed with a hand-held device (Vscan 1.2) could identify patients with LVEF <50%, and (2) the distribution of HF types among patients with suspected HF seen at primary care clinics.MethodsFCU performed by general practitioners (GPs)/GP registrars after a training programme comprising 20 supervised FCU examinations were compared with the corresponding results from conventional cardiac ultrasound by specialists. The agreement between groups of estimated LVEF <50%, after visual assessment of global left ventricular function, was compared. Types of HF were determined according to the outcomes from the reference examinations and serum levels of natriuretic peptides (NT-proBNP).ResultsOne hundred patients were examined by FCU that was performed by 1-4 independent examiners as well as by the reference method, contributing to 140 examinations (false positive rate, 19.0%; false negative rate, 52.6%; sensitivity, 47.4% [95% confidence interval [CI]: 27.3-68.3]; specificity, 81.0% [95% CI: 73.1-87.0]; Cohen's kappa measure for agreement=0.22 [95% CI: 0.03-0.40]). Among patients with false negative examinations, 1/7 had HF with LVEF <40%, while the others had HF with LVEF 40-49% or did not meet the full criteria for HF. In patients with NT-proBNP >125ng/L and fulfilling the criteria for HF (68/94), HF with preserved LVEF (>= 50%) predominated, followed by mid-range (40-49%) or reduced LVEF (<40%) HF types (53.2, 11.7 and 7.4%, respectively).ConclusionsThere was poor agreement between expert examiners using standard ultrasound equipment and non-experts using a handheld ultrasound device to identify patients with reduced LVEF. Asides from possible shortcomings of the training programme, the poor performance of non-experts could be explained by their limited experience in identifying left ventricular dysfunction because of the low percentage of patients with HF and reduced ejection fraction seen in the primary care setting.Trial registrationThe study was registered at ClinicalTrials.gov (NCT02939157). Registered 19 October 2016.

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