JBS 2: Joint British Societies' guidelines on prevention of cardiovascular disease in clinical practice

Effects of risk assessment and management programme for hypertension on clinical outcomes and cardiovascular disease risks after 12 months: a population-based matched cohort study

Objectives:

This study evaluated the effectiveness of a structured multidisciplinary risk assessment and management programme for patients with hypertension (RAMP-HT) who were managed in public primary care clinics but had suboptimal blood pressure (BP) control in improving BP, LDL-cholesterol (LDL-C) and predicted 10-year cardiovascular disease (CVD) risk after 12 months of intervention.

Methods:

A total of 10 262 hypertension patients with suboptimal BP despite treatment, aged less than 80 years and without existing CVD were enrolled in RAMP-HT between October 2011 and March 2012 from public general out-patient clinics in Hong Kong. Their clinical outcomes and predicted 10-year CVD risk were compared with a matched cohort of hypertension patients who were receiving usual care in general out-patient clinics without any RAMP-HT intervention by propensity score matching. Multivariable linear and logistic regressions were used to determine the independent effectiveness of RAMP-HT after adjusting for potential confounding variables.

Results:

Compared with the usual care group after 12 months, significantly greater proportions of RAMP-HT participants achieved target BP (i.e. BP < 140/90 mmHg) (OR = 1.18, P < 0.01) and LDL-C levels (i.e. <3.4 mmol/l for patients with CVD risk ≤20% or <2.6 mmol/l for CVD risk >20%) (OR = 1.13, P < 0.01). RAMP-HT participants also had significantly greater reduction in predicted 10-year CVD risk by 0.44% (coefficient = −0.44, P < 0.01).

Conclusion:

The structured multidisciplinary RAMP-HT was more effective than usual care in achieving target BP, LDL-C and reducing predicted 10-year CVD risk in public primary care patients with suboptimal hypertension control after 12 months of intervention. A long-term follow-up should be conducted to confirm whether the improvement in clinical outcomes can be translated into actual reductions in CVD complications and mortalities and whether such approach is cost-effective.

Influence of arterial hypertension, type 2 diabetes and cardiovascular risk factors on ALS outcome: a population-based study

OBJECTIVE

To assess the prognostic influence of pre-morbid type 2 diabetes mellitus, arterial hypertension and cardiovascular (CV) risk profile on ALS phenotype and outcome in a population-based cohort of Italian patients.

METHODS

A total of 650 ALS patients from the Piemonte/Valle d'Aosta Register for ALS, incident in the 2007-2011 period, were recruited. Information about premorbid presence of type 2 diabetes mellitus, arterial hypertension was collected at the time of diagnosis. Patients' CV risk profile was calculated according to the Joint British Societies' guidelines on prevention of cardiovascular disease in clinical practice (JBS2).

RESULTS

At the univariate analysis, the presence of pre-morbid arterial hypertension was associated with a higher age at onset of ALS and a shorter survival, and patients with a high CV risk profile had a worse prognosis than those with a low CV risk profile. The Cox multivariable analysis did not confirm such findings. Type 2 diabetes mellitus did not modify either the phenotype or the prognosis of ALS patients.

CONCLUSIONS

This study performed on a large population-based cohort of ALS patients has demonstrated that arterial hypertension, type 2 diabetes and CV risk factors, calculated using the Framingham equation, do not influence ALS phenotype and prognosis.

Greater ability to express positive emotion is associated with lower projected cardiovascular disease risk

Positive emotion is associated with lower cardiovascular disease (CVD) risk, yet some mechanisms remain unclear. One potential pathway is via emotional competencies/skills. The present study tests whether the ability to facially express positive emotion is associated with CVD risk scores, while controlling for potential confounds and testing for sex moderation. Eighty-two men and women underwent blood draws before completing self-report assessments and a performance test of expressive skill. Positive expressions were scored for degree of 'happiness' using expression coding software. CVD risk scores were calculated using established algorithms based on biological, demographic, and behavioral risk factors. Linear regressions revealed a main effect for skill, with skill in expressing positive emotion associated with lower CVD risk scores. Analyses also revealed a sex-by-skill interaction whereby links between expressive skill and CVD risk scores were stronger among men. Objective tests of expressive skill have methodological advantages, appear to have links to physical health, and offer a novel avenue for research and intervention.

An evidence-based approach to the use of telehealth in long-term health conditions: development of an intervention and evaluation through pragmatic randomised controlled trials in patients with depression or raised cardiovascular risk

Background

Health services internationally are exploring the potential of telehealth to support the management of the growing number of people with long-term conditions (LTCs).

Aim

To develop, implement and evaluate new care programmes for patients with LTCs, focusing on two common LTCs as exemplars: depression or high cardiovascular disease (CVD) risk.

Methods

Development

We synthesised quantitative and qualitative evidence on the effectiveness of telehealth for LTCs, conducted a qualitative study based on interviews with patients and staff and undertook a postal survey to explore which patients are interested in different forms of telehealth. Based on these studies we developed a conceptual model [TElehealth in CHronic disease (TECH) model] as a framework for the development and evaluation of the Healthlines Service for patients with LTCs.

Implementation

The Healthlines Service consisted of regular telephone calls to participants from health information advisors, supporting them to make behaviour change and to use tailored online resources. Advisors sought to optimise participants’ medication and to improve adherence.

Evaluation

The Healthlines Service was evaluated with linked pragmatic randomised controlled trials comparing the Healthlines Service plus usual care with usual care alone, with nested process and economic evaluations. Participants were adults with depression or raised CVD risk recruited from 43 general practices in three areas of England. The primary outcome was response to treatment and the secondary outcomes included anxiety (depression trial), individual risk factors (CVD risk trial), self-management skills, medication adherence, perceptions of support, access to health care and satisfaction with treatment.

Trial results

Depression trial

In total, 609 participants were randomised and the retention rate was 86%. Response to treatment [Patient Health Questionnaire 9-items (PHQ-9) reduction of ≥ 5 points and score of < 10 after 4 months] was higher in the intervention group (27%, 68/255) than in the control group (19%, 50/270) [odds ratio 1.7, 95% confidence interval (CI) 1.1 to 2.5;p = 0.02]. Anxiety also improved. Intervention participants reported better access to health support, greater satisfaction with treatment and small improvements in self-management, but not improved medication adherence.

CVD risk trial

In total, 641 participants were randomised and the retention rate was 91%. Response to treatment (maintenance of/reduction in QRISK®2 score after 12 months) was higher in the intervention group (50%, 148/295) than in the control group (43%, 124/291), which does not exclude a null effect (odds ratio 1.3, 95% CI 1.0 to 1.9;p = 0.08). The intervention was associated with small improvements in blood pressure and weight, but not smoking or cholesterol. Intervention participants were more likely to adhere to medication, reported better access to health support and greater satisfaction with treatment, but few improvements in self-management.

The Healthlines Service was likely to be cost-effective for CVD risk, particularly if the benefits are sustained, but not for depression. The intervention was implemented largely as planned, although initial delays and later disruption to delivery because of the closure of NHS Direct may have adversely affected participant engagement.

Conclusion

The Healthlines Service, designed using an evidence-based conceptual model, provided modest health benefits and participants valued the better access to care and extra support provided. This service was cost-effective for CVD risk but not depression. These findings of small benefits at extra cost are consistent with previous pragmatic research on the implementation of comprehensive telehealth programmes for LTCs.

Trial registration

Current Controlled Trials ISRCTN14172341 (depression trial) and ISRCTN27508731 (CVD risk trial).

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Primary care organisational interventions for secondary prevention of ischaemic heart disease: a systematic review and meta-analysis

BACKGROUND

Ischaemic heart disease (IHD) is the most common cause of death worldwide.

AIM

To determine the long-term impact of organisational interventions for secondary prevention of IHD.

DESIGN AND SETTING

Systematic review and meta-analysis of studies from CENTRAL, MEDLINE(®), Embase, and CINAHL published January 2007 to January 2013.

METHOD

Searches were conducted for randomised controlled trials of patients with established IHD, with long-term follow-up, of cardiac secondary prevention programmes targeting organisational change in primary care or community settings. A random-effects model was used and risk ratios were calculated.

RESULTS

Five studies were included with 4005 participants. Meta-analysis of four studies with mortality data at 4.7-6 years showed that organisational interventions were associated with approximately 20% reduced mortality, with a risk ratio (RR) for all-cause mortality of 0.79 (95% confidence interval [CI] = 0.66 to 0.93), and a RR for cardiac-related mortality of 0.74 (95% CI = 0.58 to 0.94). Two studies reported mortality data at 10 years. Analysis of these data showed no significant differences between groups. There were insufficient data to conduct a meta-analysis on the effect of interventions on hospital admissions. Additional analyses showed no significant association between organisational interventions and risk factor management or appropriate prescribing at 4.7-6 years.

CONCLUSION

Cardiac secondary prevention programmes targeting organisational change are associated with a reduced risk of death for at least 4-6 years. There is insufficient evidence to conclude whether this beneficial effect is maintained indefinitely.

Diagnostic inertia in obesity and the impact on cardiovascular risk in primary care: a cross-sectional study

BACKGROUND

Prevalence of diagnostic inertia (DI), defined as a failure to diagnose disease, has not been analysed in patients with obesity.

AIM

To quantify DI for cardiovascular risk factors (CVRF) in patients with obesity, and determine its association with the cardiovascular risk score.

DESIGN AND SETTING

Cross-sectional study of people ≥40 years attending a preventive programme in primary healthcare centres in Spain in 2003-2004.

METHOD

All patients with obesity attending during the first 6 months of the preventive programme were analysed. Participants had to be free of CVD (myocardial ischaemia or stroke) and aged 40-65 years; the criteria used to measure SCORE (Systematic COronary Risk Evaluation). Three subgroups of patients with obesity with no personal history of CVRF but with poor control of risk factors were established. Outcome variable was DI, defined as poor control of risk factors and no action taken by the physician. Secondary variables were diabetes, fasting blood glucose (FBG), body mass index (BMI), and SCORE. Adjusted odds ratios (OR) was determined using multivariate logistic regression models.

RESULTS

Of 8687 patients with obesity in the programme, 6230 fulfilled SCORE criteria. Prevalence of DI in the three subgroups was: hypertension, 1275/1816 (70.2%) patients affected (95% CI = 68.1 to 72.3%); diabetes, 335/359 (93.3%) patients affected (95% CI = 90.7 to 95.9%); dyslipidaemia subgroup, 1796/3341 (53.8%) patients affected (95% CI = 52.1 to 55.4%. Factors associated with DI for each subgroup were: for hypertension, absence of diabetes, higher BMI, and greater cardiovascular risk; for dyslipidaemia, diabetes, higher BMI, and greater cardiovascular risk (SCORE); and for diabetes, lower FBG levels, lower BMI, and greater cardiovascular risk.

CONCLUSION

This study quantified DI in patients with obesity and determined that it was associated with a greater cardiovascular risk.

Changes in diet, exercise and stress behaviours using the stages of change model in cardiac rehabilitation patients

The behavioural changes initiated during Phase III cardiac rehabilitation programmes were recorded using Prochaska and Diclemente's “stages of change” model. This study aimed to ascertain if changes were initiated, maintained or further developed during Phase III programmes and 6 months after the programmes with a view to ascertaining the usefulness of this tool in providing stage matched individualised care. The risk factors examined were: exercise, diet and stress. The stages were recorded quantitatively and were numerically designated a value of 1–5. The results were analysed using SPSS. The sample number was one hundred and eighty seven patients.

Significant improvements were made by the end of the programme (6 or 8 weeks) indicating that most patients had modified their behaviour during the programme. There was no significant additional improvement in the risk factors 6 months later. These results are a further indication of the need for support post Phase III programmes. Patients entered Phase III rehabilitation at different stages in their risk behaviours and with regard to exercise this stage at commencement influences the final stage achieved. “Stages of change” is a useful simple method of recording behavioural change and this type of routine monitoring of a patient could be used effectively as part of the individual care plan during the programme.

Reductions in Atherogenic Lipids and Major Cardiovascular Events: A Pooled Analysis of 10 ODYSSEY Trials Comparing Alirocumab With Control

Supplemental Digital Content is available in the text.

Background:

A continuous relationship between reductions in low-density lipoprotein cholesterol (LDL-C) and major adverse cardiovascular events (MACE) has been observed in statin and ezetimibe outcomes trials down to achieved levels of 54 mg/dL. However, it is uncertain whether this relationship extends to LDL-C levels <50 mg/dL. We assessed the relationship between additional LDL-C, non–high-density lipoprotein cholesterol, and apolipoprotein B100 reductions and MACE among patients within the ODYSSEY trials that compared alirocumab with controls (placebo/ezetimibe), mainly as add-on therapy to maximally tolerated statin.

Methods:

Data were pooled from 10 double-blind trials (6699 patient-years of follow-up). Randomization was to alirocumab 75/150 mg every 2 weeks or control for 24 to 104 weeks, added to background statin therapy in 8 trials. This analysis included 4974 patients (3182 taking alirocumab, 1174 taking placebo, 618 taking ezetimibe). In a post hoc analysis, the relationship between average on-treatment lipid levels and percent reductions in lipids from baseline were correlated with MACE (coronary heart disease death, nonfatal myocardial infarction, ischemic stroke, or unstable angina requiring hospitalization) in multivariable analyses.

Results:

Overall, 33.1% of the pooled cohort achieved average LDL-C <50 mg/dL (44.7%–52.6% allocated to alirocumab, 6.5% allocated to ezetimibe, and 0% allocated to placebo). In total, 104 patients experienced MACE (median time to event, 36 weeks). For every 39 mg/dL lower achieved LDL-C, the risk of MACE appeared to be 24% lower (adjusted hazard ratio, 0.76; 95% confidence interval, 0.63–0.91; P=0.0025). Percent reductions in LDL-C from baseline were inversely correlated with MACE rates (hazard ratio, 0.71; 95% confidence interval, 0.57–0.89 per additional 50% reduction from baseline; P=0.003). Strengths of association materially similar to those described for LDL-C were observed with achieved non–high-density lipoprotein cholesterol and apolipoprotein B100 levels or percentage reductions.

Conclusions:

In a post hoc analysis from 10 ODYSSEY trials, greater percentage reductions in LDL-C and lower on-treatment LDL-C were associated with a lower incidence of MACE, including very low levels of LDL-C (<50 mg/dL). These findings require further validation in the ongoing prospective ODYSSEY OUTCOMES trial.

Clinical Trial Registration:

URL: https://www.clinicaltrials.gov. Unique identifiers: NCT01507831, NCT01623115, NCT01709500, NCT01617655, NCT01644175, NCT01644188, NCT01644474, NCT01730040, NCT01730053, and NCT01709513.

Cost-effectiveness modelling of telehealth for patients with raised cardiovascular disease risk: evidence from a cohort simulation conducted alongside the Healthlines randomised controlled trial

OBJECTIVES

To investigate the long-term cost-effectiveness (measured as the ratio of incremental NHS cost to incremental quality-adjusted life years) of a telehealth intervention for patients with raised cardiovascular disease (CVD) risk.

DESIGN

A cohort simulation model developed as part of the economic evaluation conducted alongside the Healthlines randomised controlled trial.

SETTING

Patients recruited through primary care, and intervention delivered via telehealth service.

PARTICIPANTS

Participants with a 10-year CVD risk ≥20%, as measured by the QRISK2 algorithm, and with at least 1 modifiable risk factor, individually randomised from 42 general practices in England.

INTERVENTION

A telehealth service delivered over a 12-month period. The intervention involved a series of responsive, theory-led encounters between patients and trained health information advisors who provided access to information resources and supported medication adherence and coordination of care.

PRIMARY AND SECONDARY OUTCOME MEASURES

Cost-effectiveness measured by net monetary benefit over the simulated lifetime of trial participants from a UK National Health Service perspective.

RESULTS

The probability that the intervention was cost-effective depended on the duration of the effect of the intervention. The intervention was cost-effective with high probability if effects persisted over the lifetime of intervention recipients. The probability of cost-effectiveness was lower for shorter durations of effect.

CONCLUSIONS

The intervention was likely to be cost-effective under a lifetime perspective.

TRIAL REGISTRATION NUMBER

ISRCTN27508731; Results.

Energy compensation following consumption of sugar-reduced products: a randomized controlled trial

PURPOSE

Consumption of sugar-reformulated products (commercially available foods and beverages that have been reduced in sugar content through reformulation) is a potential strategy for lowering sugar intake at a population level. The impact of sugar-reformulated products on body weight, energy balance (EB) dynamics and cardiovascular disease risk indicators has yet to be established. The REFORMulated foods (REFORM) study examined the impact of an 8-week sugar-reformulated product exchange on body weight, EB dynamics, blood pressure, arterial stiffness, glycemia and lipemia.

METHODS

A randomized, controlled, double-blind, crossover dietary intervention study was performed with fifty healthy normal to overweight men and women (age 32.0 ± 9.8 year, BMI 23.5 ± 3.0 kg/m(2)) who were randomly assigned to consume either regular sugar or sugar-reduced foods and beverages for 8 weeks, separated by 4-week washout period. Body weight, energy intake (EI), energy expenditure and vascular markers were assessed at baseline and after both interventions.

RESULTS

We found that carbohydrate (P < 0.001), total sugars (P < 0.001) and non-milk extrinsic sugars (P < 0.001) (% EI) were lower, whereas fat (P = 0.001) and protein (P = 0.038) intakes (% EI) were higher on the sugar-reduced than the regular diet. No effects on body weight, blood pressure, arterial stiffness, fasting glycemia or lipemia were observed.

CONCLUSIONS

Consumption of sugar-reduced products, as part of a blinded dietary exchange for an 8-week period, resulted in a significant reduction in sugar intake. Body weight did not change significantly, which we propose was due to energy compensation.

Serum 25-hydroxyvitamin D and insulin resistance in people at high risk of cardiovascular disease: a euglycaemic hyperinsulinaemic clamp study

CONTEXT

In observational studies, low serum 25-hydroxyvitamin D (25-OHD) concentration is associated with an increased risk of type 2 diabetes mellitus (DM). Increasing serum 25-OHD may have beneficial effects on insulin resistance or beta-cell function. Cross-sectional studies utilizing suboptimal methods for assessment of insulin sensitivity and serum 25-OHD concentration provide conflicting results.

OBJECTIVE

This study examined the relationship between serum 25-OHD concentration and insulin resistance in healthy overweight individuals at increased risk of cardiovascular disease, using optimal assessment techniques.

METHODS

A total of 92 subjects (mean age 56·0, SD 6·0 years), who were healthy but overweight (mean body mass index 30·9, SD 2·3 kg/m(2) ), underwent assessments of insulin sensitivity (two-step euglycaemic hyperinsulinaemic clamp, HOMA2-IR), beta-cell function (HOMA2%B), serum 25-OHD concentration and body composition (DEXA).

RESULTS

Mean total 25-OHD concentration was 32·2, range 21·8-46·6 nmol/l. No association was demonstrated between serum 25-OHD concentration and insulin resistance.

CONCLUSIONS

In this study using optimal assessment techniques to measure 25-OHD concentration, insulin sensitivity and body composition, there was no association between serum 25-OHD concentration and insulin resistance in healthy, overweight individuals at high risk of developing cardiovascular disease. This study suggests the documented inverse association between serum 25-OHD concentration and risk of type 2 DM is not mediated by a relationship between serum 25-OHD concentration and insulin resistance.

Secondary prevention programmes for coronary heart disease: a meta-regression showing the merits of shorter, generalist, primary care-based interventions

Background

The aim of this study was to determine which programme characteristics influence the effectiveness of secondary prevention programmes for Coronary Heart Disease.

Design

The study follows a meta-regression design.

Methods

We conducted a meta-regression within a systematic review of randomized trials comparing secondary prevention programmes versus usual care. The primary outcome was all-cause mortality. Studies were identified by searching multiple electronic databases, bibliographies of published studies, contact with experts, and references provided by the United States Centers for Medicare and Medicaid Services. Primary authors of all relevant trials were surveyed for detailed information on programme characteristics. Forty-six unique trials were identified (18 821 patients). The pooled all-cause mortality risk ratio (RR) for programmes was 0.87 [95% confidence interval (CI) 0.79-0.97]. Programmes containing less than 10 h of patient contact with health professionals reduced all-cause mortality (RR 0.80, 95% CI 0.68-0.95) as effectively as programmes with more contact time. Programmes provided in general practice settings were effective at reducing all-cause mortality (RR 0.76, 95% CI 0.63-0.92) and compared favourably with the effectiveness of hospital-based programmes. Other characteristics, including specialist versus generalist provision, did not appreciably impact programme effectiveness.

Conclusions

Shorter secondary prevention programmes, those based in general practice, and those staffed by generalists are at least as effective in reducing all cause mortality in patients with coronary heart disease as longer programmes, hospital-based programmes, and programmes staffed by specialists.

The Alphabet Strategy and standards of care in young adults with type 1 diabetes

The Alphabet Strategy is a mnemonic-based approach to assist commitment to important aspects of diabetes care: Advice; Blood pressure lowering; Cholesterol and creatinine control; Diabetes control; Eye examination; Foot examination; and use of Guardian drugs. This strategy reported high standards of care of patients with type 2 diabetes. This study assesses the impact of the Alphabet Strategy on diabetes management in young adults with type 1 diabetes and compared data with those of a recently published multicentre study. Results were analysed using the chi-square test and Student's t-test.

Data were collected retrospectively from 68 patients with type 1 diabetes aged 16—25 years attending the George Eliot Hospital (GEH) adolescent diabetes clinic and who were being managed as per The Alphabet Strategy.

Standards of diabetes care in the GEH clinic were better than those reported in the multicentre study. GEH versus multicentre study: clinic non-attendance 12% vs. 24.6%: mean HbA1C% 8.4 vs. 9.5, p<0.001: screening rates; hypertension 100% vs. 88%, p<0.05; nephropathy 80% vs. 56%, p<0.01; retinopathy 98% in GEH clinic: prevalence of complications; nephropathy 5% vs. 21%, p<0.02; retinopathy 24% vs. 28%, not significant.

In conclusion, we found regular clinic visits and separate adolescent clinics improve glycaemic control. The Alphabet Strategy may be considered an effective approach in monitoring/screening and attaining targets in young adults with type 1 diabetes.

BAP guidelines on the management of weight gain, metabolic disturbances and cardiovascular risk associated with psychosis and antipsychotic drug treatment

Excess deaths from cardiovascular disease are a major contributor to the significant reduction in life expectancy experienced by people with schizophrenia. Important risk factors in this are smoking, alcohol misuse, excessive weight gain and diabetes. Weight gain also reinforces service users' negative views of themselves and is a factor in poor adherence with treatment. Monitoring of relevant physical health risk factors is frequently inadequate, as is provision of interventions to modify these. These guidelines review issues surrounding monitoring of physical health risk factors and make recommendations about an appropriate approach. Overweight and obesity, partly driven by antipsychotic drug treatment, are important factors contributing to the development of diabetes and cardiovascular disease in people with schizophrenia. There have been clinical trials of many interventions for people experiencing weight gain when taking antipsychotic medications but there is a lack of clear consensus regarding which may be appropriate in usual clinical practice. These guidelines review these trials and make recommendations regarding appropriate interventions. Interventions for smoking and alcohol misuse are reviewed, but more briefly as these are similar to those recommended for the general population. The management of impaired fasting glycaemia and impaired glucose tolerance ('pre-diabetes'), diabetes and other cardiovascular risks, such as dyslipidaemia, are also reviewed with respect to other currently available guidelines.These guidelines were compiled following a consensus meeting of experts involved in various aspects of these problems. They reviewed key areas of evidence and their clinical implications. Wider issues relating to primary care/secondary care interfaces are discussed but cannot be resolved within guidelines such as these.

Optimal strategies for monitoring lipid levels in patients at risk or with cardiovascular disease: a systematic review with statistical and cost-effectiveness modelling

BACKGROUND

Various lipid measurements in monitoring/screening programmes can be used, alone or in cardiovascular risk scores, to guide treatment for prevention of cardiovascular disease (CVD). Because some changes in lipids are due to variability rather than true change, the value of lipid-monitoring strategies needs evaluation.

OBJECTIVE

To determine clinical value and cost-effectiveness of different monitoring intervals and different lipid measures for primary and secondary prevention of CVD.

DATA SOURCES

We searched databases and clinical trials registers from 2007 (including the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, the Clinical Trials Register, the Current Controlled Trials register, and the Cumulative Index to Nursing and Allied Health Literature) to update and extend previous systematic reviews. Patient-level data from the Clinical Practice Research Datalink and St Luke's Hospital, Japan, were used in statistical modelling. Utilities and health-care costs were drawn from the literature.

METHODS

In two meta-analyses, we used prospective studies to examine associations of lipids with CVD and mortality, and randomised controlled trials to estimate lipid-lowering effects of atorvastatin doses. Patient-level data were used to estimate progression and variability of lipid measurements over time, and hence to model lipid-monitoring strategies. Results are expressed as rates of true-/false-positive and true-/false-negative tests for high lipid or high CVD risk. We estimated incremental costs per quality-adjusted life-year.

RESULTS

A total of 115 publications reported strength of association between different lipid measures and CVD events in 138 data sets. The summary adjusted hazard ratio per standard deviation of total cholesterol (TC) to high-density lipoprotein (HDL) cholesterol ratio was 1.25 (95% confidence interval 1.15 to 1.35) for CVD in a primary prevention population but heterogeneity was high (I(2) = 98%); similar results were observed for non-HDL cholesterol, apolipoprotein B and other ratio measures. Associations were smaller for other single lipid measures. Across 10 trials, low-dose atorvastatin (10 and 20 mg) effects ranged from a TC reduction of 0.92 mmol/l to 2.07 mmol/l, and low-density lipoprotein reduction of between 0.88 mmol/l and 1.86 mmol/l. Effects of 40 mg and 80 mg were reported by one trial each. For primary prevention, over a 3-year period, we estimate annual monitoring would unnecessarily treat 9 per 1000 more men (28 vs. 19 per 1000) and 5 per 1000 more women (17 vs. 12 per 1000) than monitoring every 3 years. However, annual monitoring would also undertreat 9 per 1000 fewer men (7 vs. 16 per 1000) and 4 per 1000 fewer women (7 vs. 11 per 1000) than monitoring at 3-year intervals. For secondary prevention, over a 3-year period, annual monitoring would increase unnecessary treatment changes by 66 per 1000 men and 31 per 1000 women, and decrease undertreatment by 29 per 1000 men and 28 per 1000 men, compared with monitoring every 3 years. In cost-effectiveness, strategies with increased screening/monitoring dominate. Exploratory analyses found that any unknown harms of statins would need utility decrements as large as 0.08 (men) to 0.11 (women) per statin user to reverse this finding in primary prevention.

LIMITATION

Heterogeneity in meta-analyses.

CONCLUSIONS

While acknowledging known and potential unknown harms of statins, we find that more frequent monitoring strategies are cost-effective compared with others. Regular lipid monitoring in those with and without CVD is likely to be beneficial to patients and to the health service. Future research should include trials of the benefits and harms of atorvastatin 40 and 80 mg, large-scale surveillance of statin safety, and investigation of the effect of monitoring on medication adherence.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013003727.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Ezetimibe-Statin Combination Therapy

BACKGROUND

To date, most clinical comparisons of ezetimibe-statin combination therapy versus statin monotherapy have relied entirely on surrogate variables. In this systematic review, we study the efficacy and safety of ezetimibe-statin combination therapy in comparison to statin monotherapy in terms of the prevention of cardiovascular events in hyperlipidemic patients with atherosclerosis and/or diabetes mellitus.

METHODS

This review is based on a systematic literature search (1995 to July 2015) in PubMed, the Excerpta Medica Database (EMBASE), the Cochrane Library, and the ClinicalTrials.gov registry.

RESULTS

Nine randomized, controlled trials with data from a total of 19 461 patients were included. Ezetimibe-statin combination therapy was associated with a lower risk of cardiovascular events than statin monotherapy: 33% of the patients treated with ezetimibe and a statin, and 35% of those treated with a statin alone, had a cardiovascular event within seven years (number needed to treat [NNT]: 50 over 7 years). Combination therapy was also significantly more effective in preventing a composite endpoint consisting of death due to cardiovascular disease, nonfatal myocardial infarction, unstable angina pectoris, coronary revascularization, and nonfatal stroke (hazard ratio [HR] 0.94, 95% confidence interval [0,89; 0,99]; p = 0.016). Diabetic patients benefited from combination therapy rather than monotherapy with respect to cardiovascular morbidity (HR 0.87 [0.78; 0.94]). On the other hand, the addition of ezetimibe to statin therapy did not lessen either cardiovascular or overall mortality. Serious undesired events occurred in 38% of the patients taking ezetimibe and a statin nd in 39% of the patients taking a statin alone (relative risk 1.09 [0.77; 1.55]).

CONCLUSION

In high-risk patients with an acute coronary syndrome, combination therapy with ezetimibe and a statin lowered the risk of cardiovascular events in comparison to statin monotherapy. The risk of dying or suffering an adverse drug effect was similar in the two treatment groups.

Outcomes of a community-based weight management programme for morbidly obese populations

BACKGROUND

Morbid obesity is an ongoing concern worldwide. There is a paucity of research reporting primary care outcomes focussed on complex and morbidly obese populations. The National Institute for Health and Care Excellence (NICE) recommends a specialist, multidisciplinary weight management team for the successful management of such populations. This is the first service evaluation reporting both primary (weight change) and secondary [body mass index (BMI), waist circumference, physical activity levels, fruit and vegetable intake, Rosenberg self-esteem score] outcomes in these patients.

METHODS

The present study comprised a prospective observational study of a cohort data set for patients (n = 288) attending their 3-month and 6-month (n = 115) assessment appointments at a specialist community weight management programme.

RESULTS

Patients had a mean (SD) initial BMI of 45.5 (6.6) kg m^- ²; 66% were females. Over 80% of patients attending the service lost some weight by 3 months. Average absolute weight loss was 4.11 (4.95) kg at 3 months and 6.30 (8.41) kg at 6 months, equating to 3.28% (3.82%) and 4.90% (6.26%), respectively, demonstrating a statistically significant weight change at both time points (P < 0.001). This meets NICE best practice guidelines for the commissioning of services leading to a minimum of 3% average weight loss, with at least 30% of patients losing at ≥5% of their initial weight. Waist measurement and BMI were reduced significantly at 3 months. Improvements were also seen in physical activity levels, fruit and vegetable consumption, and self-esteem levels (P < 0.001).

CONCLUSIONS

This service was successful in aiding weight loss in morbidly obese populations. The findings of the present study support the view that weight-loss targets of 3% are realistic.

A cardiovascular disease policy model: part 2-preparing for economic evaluation and to assess health inequalities

Objectives

This is the second of the two papers introducing a cardiovascular disease (CVD) policy model. The first paper described the structure and statistical underpinning of the state-transition model, demonstrating how life expectancy estimates are generated for individuals defined by ASSIGN risk factors. This second paper describes how the model is prepared to undertake economic evaluation.

Design

To generate quality-adjusted life expectancy (QALE), the Scottish Health Survey was used to estimate background morbidity (health utilities) and the impact of CVD events (utility decrements). The SF-6D algorithm generated utilities and decrements were modelled using ordinary least squares (OLS). To generate lifetime hospital costs, the Scottish Heart Health Extended Cohort (SHHEC) was linked to the Scottish morbidity and death records (SMR) to cost each continuous inpatient stay (CIS). OLS and restricted cubic splines estimated annual costs before and after each of the first four events. A Kaplan-Meier sample average (KMSA) estimator was then used to weight expected health-related quality of life and costs by the probability of survival.

Results

The policy model predicts the change in QALE and lifetime hospital costs as a result of an intervention(s) modifying risk factors. Cost-effectiveness analysis and a full uncertainty analysis can be undertaken, including probabilistic sensitivity analysis. Notably, the impacts according to socioeconomic deprivation status can be made.

Conclusions

The policy model can conduct cost-effectiveness analysis and decision analysis to inform approaches to primary prevention, including individually targeted and population interventions, and to assess impacts on health inequalities.

Telehealth for patients at high risk of cardiovascular disease: pragmatic randomised controlled trial

OBJECTIVE

 To assess whether non-clinical staff can effectively manage people at high risk of cardiovascular disease using digital health technologies.

DESIGN

 Pragmatic, multicentre, randomised controlled trial.

SETTING

 42 general practices in three areas of England.

PARTICIPANTS

 Between 3 December 2012 and 23 July 2013 we recruited 641 adults aged 40 to 74 years with a 10 year cardiovascular disease risk of 20% or more, no previous cardiovascular event, at least one modifiable risk factor (systolic blood pressure ≥140 mm Hg, body mass index ≥30, current smoker), and access to a telephone, the internet, and email. Participants were individually allocated to intervention (n=325) or control (n=316) groups using automated randomisation stratified by site, minimised by practice and baseline risk score.

INTERVENTIONS

 Intervention was the Healthlines service (alongside usual care), comprising regular telephone calls from trained lay health advisors following scripts generated by interactive software. Advisors facilitated self management by supporting participants to use online resources to reduce risk factors, and sought to optimise drug use, improve treatment adherence, and encourage healthier lifestyles. The control group comprised usual care alone.

MAIN OUTCOME MEASURES

 The primary outcome was the proportion of participants responding to treatment, defined as maintaining or reducing their cardiovascular risk after 12 months. Outcomes were collected six and 12 months after randomisation and analysed masked. Participants were not masked.

RESULTS

 50% (148/295) of participants in the intervention group responded to treatment compared with 43% (124/291) in the control group (adjusted odds ratio 1.3, 95% confidence interval 1.0 to 1.9; number needed to treat=13); a difference possibly due to chance (P=0.08). The intervention was associated with reductions in blood pressure (difference in mean systolic -2.7 mm Hg (95% confidence interval -4.7 to -0.6 mm Hg), mean diastolic -2.8 (-4.0 to -1.6 mm Hg); weight -1.0 kg (-1.8 to -0.3 kg), and body mass index -0.4 ( -0.6 to -0.1) but not cholesterol -0.1 (-0.2 to 0.0), smoking status (adjusted odds ratio 0.4, 0.2 to 1.0), or overall cardiovascular risk as a continuous measure (-0.4, -1.2 to 0.3)). The intervention was associated with improvements in diet, physical activity, drug adherence, and satisfaction with access to care, treatment received, and care coordination. One serious related adverse event occurred, when a participant was admitted to hospital with low blood pressure.

CONCLUSIONS

 This evidence based telehealth approach was associated with small clinical benefits for a minority of people with high cardiovascular risk, and there was no overall improvement in average risk. The Healthlines service was, however, associated with improvements in some risk behaviours, and in perceptions of support and access to care.Trial registration Current Controlled Trials ISRCTN 27508731.

Towards Tailored Patient's Management Approach: Integrating the Modified 2010 ACR Criteria for Fibromyalgia in Multidimensional Patient Reported Outcome Measures Questionnaire

Objectives. To assess the validity, reliability, and responsiveness to change of a patient self-reported questionnaire combining the Widespread Pain Index and the Symptom Severity Score as well as construct outcome measures and comorbidities assessment in fibromyalgia patients. Methods. The PROMs-FM was conceptualized based on frameworks used by the WHO Quality of Life tool and the PROMIS. Initially, cognitive interviews were conducted to identify item pool of questions. Item selection and reduction were achieved based on patients as well as an interdisciplinary group of specialists. Rasch and internal consistency reliability analyses were implemented. The questionnaire included the modified ACR criteria main items (Symptom Severity Score and Widespread Pain Index), in addition to assessment of functional disability, quality of life (QoL), review of the systems, and comorbidities. Every patient completed HAQ and EQ-5D questionnaires. Results. A total of 146 fibromyalgia patients completed the questionnaire. The PROMs-FM questionnaire was reliable as demonstrated by a high standardized alpha (0.886-0.982). Content construct assessment of the functional disability and QoL revealed significant correlation (p < 0.01) with both HAQ and EQ-5D. Changes in functional disability and QoL showed significant (p < 0.01) variation with diseases activity status in response to therapy. There was higher prevalence of autonomic symptoms, CVS risk, sexual dysfunction, and falling. Conclusions. The developed PROMs-FM questionnaire is a reliable and valid instrument for assessment of fibromyalgia patients. A phased treatment regimen depending on the severity of FMS as well as preferences and comorbidities of the patient is the best approach to tailored patient management.

Untreated hypertension in the UK household population - Who are missed by the general health checks?

Hypertension is an age-related, long-term condition and a leading risk factor for premature death and disability worldwide. Due to its asymptomatic nature it can often be left undiagnosed. Long-term treatment is available, but blood pressure can also be reduced through health behaviour changes in weight control, smoking cessation, higher physical activity levels, reduced salt and alcohol intake, and healthful diets if discovered early. This paper investigates the prevalence and characteristics of those with untreated (compared to treated) hypertension who did not have a history of cardiovascular disease (CVD); a group who is in effect missed by general health checks. Untreated hypertension was studied in 8933 individuals aged 40-74 years representative of the UK household population, who were interviewed and underwent a physical health examination in their home, 2010-2012. The prevalence of untreated hypertension without a history of CVD was 7% for men, 2% for women, and 5% overall. Untreated hypertension was particularly high among the 55-64 year age group. Age and sex-adjusted analyses found strong positive associations with male gender, smoking, self-reported good-excellent health, full fat dairy preference, white bread preference, higher alcohol consumption, and living alone. Strong negative associations were found for possessing 5 + prescription drugs, statins or antiplatelets, being diagnosed with diabetes or possessing antidiabetics, and long-term limiting illness status. Notably, many reported their health as good to excellent. A fact which emphasises the importance of motivating individuals to take part in the general health checks for an asymptomatic condition such as hypertension.

Risk assessment in the prevention of cardiovascular disease in low-resource settings

INTRODUCTION

Cardiovascular disease (CVD) prevalence is increasing in low- and middle-income countries. Total risk assessment is key to prevention.

METHODS

Studies and guidelines published between 1990 and 2013 were sought using Medline database, PubMed, and World Health Organization report sheets. Search terms included 'risk assessment' and 'cardiovascular disease prevention'. Observational studies and randomized controlled trials were reviewed.

RESULTS

The ideal risk prediction tool is one that is derived from the population in which it is to be applied. Without national population-based cohort studies in sub-Saharan African countries like Nigeria, there is no tool that is used consistently. Regardless of which one is adopted by national guidelines, routine consistent use is advocated by various CVD prevention guidelines.

CONCLUSIONS

In low-resource settings, the consistent use of simple tools like the WHO charts is recommended, as the benefit of a standard approach to screening outweighs the risk of missing an opportunity to prevent CVD.

Temporal Trends in Polypharmacy and Hyperpolypharmacy in Older New Zealanders over a 9-Year Period: 2005–2013

BACKGROUND

Polypharmacy and hyperpolypharmacy are proxy indicators for inappropriate medicine use. Inappropriate medicine use in older people leads to adverse clinical outcomes.

OBJECTIVE

The objectives of this study were to investigate the prevalence and trends of polypharmacy and hyperpolypharmacy in older people in New Zealand from 2005 to 2013, analyzing the pharmaceutical collections maintained by the Ministry of Health.

METHODS

A repeated cross-sectional analysis of population-level dispensing data was conducted from January 1, 2005 to December 31, 2013. Polypharmacy and hyperpolypharmacy in individuals were defined as the use of 5-9 medicines and ≥10 medicines, respectively, dispensed concurrently for a period of ≥90 days. Differences in polypharmacy and hyperpolypharmacy between 2005 and 2013 were examined. A multinomial regression model was used to predict sociodemographic characteristics associated with polypharmacy and hyperpolypharmacy.

RESULTS

Polypharmacy and hyperpolypharmacy were found to be higher in 2013 compared to 2005 (polypharmacy: 29.5 vs. 23.4%, p<0.001; hyperpolypharmacy: 2.1 vs. 1.3%, p<0.001). The risk of polypharmacy and hyperpolypharmacy was higher in females, in those aged 80-84 years, in the Māori population (for polypharmacy) and the Middle Eastern, Latin American, or African population (for hyperpolypharmacy), in people living in the Southern-district health board, and in individuals with increasing deprivation.

CONCLUSION

The population of New Zealand is aging and the number of older people with multiple chronic conditions is increasing. The proportion of older people exposed to polypharmacy and hyperpolypharmacy has increased in 2013 compared to 2005. Our study provides important information to alert health policy makers, researchers, and clinicians about the dire need to reduce the medication burden in older New Zealanders.

Incidence and predictors for cardiovascular disease in Chinese patients with type 2 diabetes mellitus - a population-based retrospective cohort study

AIMS

This study aimed to estimate the 5-year incidence rate of cardiovascular disease (CVD) and determine predictive factors of new CVD in Chinese patients with type 2 diabetes mellitus (T2DM).

METHODS

A retrospective cohort study was conducted on 115,470 T2DM patients aged ≥18 years without any history of CVD. Cox Proportional Hazard regression stratified by gender was performed to explore predictive factors of CVD.

RESULTS

For 5.3 years median follow-up, the overall incidence rate of CVD per 1,000 person-years was 17.2 (95% CI: 16.9-17.6), without significant gender difference. Predictors of higher risk of CVD were older age, current smoking, longer duration of T2DM, more severe stage of chronic kidney disease, anti-hypertensive and oral anti-diabetic drugs needed, and higher body mass index (BMI), systolic and diastolic blood pressure (SBP and DBP), total cholesterol/high-density lipoprotein-cholesterol ratio (TC/HDL-C ratio) and urine albumin/creatinine ratio (ACR). Lipid-lowering agents needed in men, and ex-smoking and higher hemoglobin A1c (HbA1c) in female were the additional predictive factors of increased CVD risk.

CONCLUSIONS

Smoking, BMI, HbA1c, SBP, DBP, TC/HDL-C ratio and ACR were found to be modifiable risk factors of new CVD in Chinese T2DM patients, which should be targeted as tertiary preventive interventions. The lack of association between HbA1c and CVD in men found in this study deserves further investigation.

Increasing fruit and vegetable intake has no effect on retinal vessel caliber in adults at high risk of developing cardiovascular disease

BACKGROUND AND AIM

Retinal vessel abnormalities are associated with cardiovascular disease (CVD) risk. To date, there are no trials investigating the effect of dietary factors on the retinal microvasculature. This study examined the dose response effect of fruit and vegetable (FV) intake on retinal vessel caliber in overweight adults at high CVD risk.

METHODS AND RESULTS

Following a 4 week washout period, participants were randomized to consume either 2 or 4 or 7 portions of FV daily for 12 weeks. Retinal vessel caliber was measured at baseline and post-intervention. A total of 62 participants completed the study. Self-reported FV intake indicated good compliance with the intervention, with serum concentrations of zeaxanthin and lutein increasing significantly across the groups in a dose-dependent manner (P for trend < 0.05). There were no significant changes in body composition, 24-h ambulatory blood pressure or fasting blood lipid profiles in response to the FV intervention. Increasing age was a significant determinant of wider retinal venules (P = 0.004) whereas baseline systolic blood pressure was a significant determinant of narrower retinal arterioles (P = 0.03). Overall, there was no evidence of any short-term dose-response effect of FV intake on retinal vessel caliber (CRAE (P = 0.92) or CRVE (P = 0.42)).

CONCLUSIONS

This study demonstrated no effect of increasing FV intake on retinal vessel caliber in overweight adults at high risk of developing primary CVD.

CLINICAL TRIAL REGISTRATION

NCT00874341.

Acute benefits of the microbial-derived isoflavone metabolite equol on arterial stiffness in men prospectively recruited according to equol producer phenotype: a double-blind randomized controlled trial

BACKGROUND

There is much speculation with regard to the potential cardioprotective benefits of equol, a microbial-derived metabolite of the isoflavone daidzein, which is produced in the large intestine after soy intake in 30% of Western populations. Although cross-sectional and retrospective data support favorable associations between the equol producer (EP) phenotype and cardiometabolic health, few studies have prospectively recruited EPs to confirm this association.

OBJECTIVE

The aim was to determine whether the acute vascular benefits of isoflavones differ according to EP phenotype and subsequently investigate the effect of providing commercially produced S-(-)equol to non-EPs.

DESIGN

We prospectively recruited male EPs and non-EPs (n = 14/group) at moderate cardiovascular risk into a double-blind, placebo-controlled crossover study to examine the acute effects of soy isoflavones (80-mg aglycone equivalents) on arterial stiffness [carotid-femoral pulse-wave velocity (cfPWV)], blood pressure, endothelial function (measured by using the EndoPAT 2000; Itamar Medical), and nitric oxide at baseline (0 h) and 6 and 24 h after intake. In a separate assessment, non-EPs consumed 40 mg S-(-)equol with identical vascular measurements performed 2 h after intake.

RESULTS

After soy intake, cfPWV significantly improved in EPs at 24 h (cfPWV change from 0 h: isoflavone, -0.2 ± 0.2 m/s; placebo, 0.6 ± 0.2 m/s; P < 0.01), which was significantly associated with plasma equol concentrations (R = -0.36, P = 0.01). No vascular effects were observed in EPs at 6 h or in non-EPs at any time point. Similarly, no benefit of commercially produced S-(-)equol was observed in non-EPs despite mean plasma equol concentrations reaching 3.2 μmol/L.

CONCLUSIONS

Acute soy intake improved cfPWV in EPs, equating to an 11-12% reduced risk of cardiovascular disease if sustained. However, a single dose of commercially produced equol had no cardiovascular benefits in non-EPs. These data suggest that the EP phenotype is critical in unlocking the vascular benefits of equol in men, and long-term trials should focus on confirming the implications of EP phenotype on cardiovascular health. This trial was registered at clinicaltrials.gov as NCT01530893.

The Stroke Prevention Programme: a programme of research to inform optimal stroke prevention in primary care

Background

The management of cardiovascular (CV) risk factors in community populations is suboptimal. The aim of this programme was to explore the role of three approaches [use of a ‘polypill’; self-management of hypertension; and more intensive targets for blood pressure (BP) lowering after stroke] to improve prevention of CV disease (CVD) in the community.

Research questions

(1) Is it more cost-effective to titrate treatments to target levels of cholesterol and BP or to use fixed doses of statins and BP-lowering agents (polypill strategy)? (2) Will telemonitoring and self-management improve BP control in people on treatment for hypertension or with a history of stroke/transient ischaemic attack (TIA) in primary care and are they cost-effective? (3) In people with a history of stroke/TIA, can intensive BP-lowering targets be achieved in a primary care setting and what impact will this have on health outcomes and cost-effectiveness?

Design

Mixed methods, comprising three randomised controlled trials (RCTs); five cost-effectiveness analyses; qualitative studies; analysis of electronic general practice data; a screening study; a systematic review; and a questionnaire study.

Setting

UK general practices, predominantly from the West Midlands and the east of England.

Participants

Adults registered with participating general practices. Inclusion criteria varied from study to study.

Interventions

A polypill – a fixed-dose combination pill containing three antihypertensive medicines and simvastatin – compared with current practice and with optimal implementation of national guidelines; self-monitoring of BP with self-titration of medication, compared with usual care; and an intensive target for systolic BP of < 130 mmHg or a 10 mmHg reduction if baseline BP is < 140 mmHg, compared with a target of < 140 mmHg.

Results

For patients known to be at high risk of CVD, treatment as per guidelines was the most cost-effective strategy. For people with unknown CV risk aged ≥ 50 years, offering a polypill is cost-effective [incremental cost-effectiveness ratio (ICER) of £8115 per quality-adjusted life-year (QALY)] compared with a strategy of screening and treating according to national guidelines. Both results were sensitive to the cost of the polypill. Self-management in people with uncontrolled hypertension led to a 5.4 mmHg [95% confidence interval (CI) 2.4 to 8.5 mmHg] reduction in systolic BP at 1 year, compared with usual care. It was cost-effective for men (ICER of £1624 per QALY) and women (ICER of £4923 per QALY). In people with stroke and other high-risk groups, self-management led to a 9.2 mmHg (95% CI 5.7 to 12.7 mmHg) reduction in systolic BP at 1 year compared with usual care and dominated (lower cost and better outcome) usual care. Aiming for the more intensive BP target after stroke led to a 2.9 mmHg (95% CI 0.2 to 5.7 mmHg) greater reduction in BP and dominated the 140 mmHg target.

Conclusions

Potential for a polypill needs to be further explored in RCTs. Self-management should be offered to people with poorly controlled BP. Management of BP in the post-stroke population should focus on achieving a < 140 mmHg target.

Trial registration

Current Controlled Trials ISRCTN17585681, ISRCTN87171227 and ISRCTN29062286.

Funding

The National Institute for Health Research (NIHR) Programme Grants for Applied Research programme. Additional funding was provided by the NIHR National School for Primary Care Research, the NIHR Career Development Fellowship and the Department of Health Policy Research Programme.

Repeat Cardiovascular Risk Assessment after Four Years: Is There Improvement in Risk Prediction?

BACKGROUND

Framingham risk equations are widely used to predict cardiovascular disease based on health information from a single time point. Little is known regarding use of information from repeat risk assessments and temporal change in estimated cardiovascular risk for prediction of future cardiovascular events. This study was aimed to compare the discrimination and risk reclassification of approaches using estimated cardiovascular risk at single and repeat risk assessments.

METHODS

Using data on 12,197 individuals enrolled in EPIC-Norfolk cohort, with 12 years of follow-up, we examined rates of cardiovascular events by levels of estimated absolute risk (Framingham risk score) at the first and second health examination four years later. We calculated the area under the receiver operating characteristic curve (aROC) and risk reclassification, comparing approaches using information from single and repeat risk assessments (i.e., estimated risk at different time points).

RESULTS

The mean Framingham risk score increased from 15.5% to 17.5% over a mean of 3.7 years from the first to second health examination. Individuals with high estimated risk (≥20%) at both health examinations had considerably higher rates of cardiovascular events than those who remained in the lowest risk category (<10%) in both health examinations (34.0 [95%CI 31.7-36.6] and 2.7 [2.2-3.3] per 1,000 person-years respectively). Using information from the most up-to-date risk assessment resulted in a small non-significant change in risk classification over the previous risk assessment (net reclassification improvement of -4.8%, p>0.05). Using information from both risk assessments slightly improved discrimination compared to information from a single risk assessment (aROC 0.76 and 0.75 respectively, p<0.001).

CONCLUSIONS

Using information from repeat risk assessments over a period of four years modestly improved prediction, compared to using data from a single risk assessment. However, this approach did not improve risk classification.

What You Don't Know: Improving Family Health History Knowledge among Multigenerational Families of Mexican Origin

BACKGROUND

This study investigated diabetes and heart disease family health history (FHH) knowledge and changes after providing personalized disease risk feedback.

METHODS

A total of 497 adults from 162 families of Mexican origin were randomized by household to conditions based on feedback recipient and content. Each provided personal and relatives' diabetes and heart disease diagnoses and received feedback materials following baseline assessment. Multivariate models were fitted to identify factors associated with the rate of 'don't know' FHH responses.

RESULTS

At baseline, US nativity was associated with a higher 'don't know' response rate (p = 0.002). Though confounded by country of birth, younger age showed a trend toward higher 'don't know' response rates. Overall, average 'don't know' response rates dropped from 20 to 15% following receipt of feedback (p < 0.001). An intervention effect was noted, as 'don't know' response rates decreased more in households where one family member (vs. all) received supplementary risk assessments (without behavioral recommendations; p = 0.011).

CONCLUSIONS

Limited FHH knowledge was noted among those born in the US and younger participants, representing a key population to reach with intervention efforts. The intervention effect suggests that 'less is more', indicating the potential for too much information to limit health education program effectiveness.

Randomised controlled pilot study to assess the feasibility of a Mediterranean Portfolio dietary intervention for cardiovascular risk reduction in HIV dyslipidaemia: a study protocol

INTRODUCTION

HIV drug treatment has greatly improved life expectancy, but increased risk of cardiovascular disease remains, potentially due to the additional burdens of infection, inflammation and antiretroviral treatment. The Mediterranean Diet has been shown to reduce cardiovascular risk and mortality in the general population, but no evidence exists for this effect in the HIV population. This study will explore the feasibility of a randomised controlled trial (RCT) to examine whether a Mediterranean-style diet that incorporates a portfolio of cholesterol-lowering foods, reduces cardiovascular risk in people with HIV dyslipidaemia.

METHODS AND ANALYSIS

60 adults with stable HIV infection on antiretroviral treatment and low-density lipoprotein cholesterol >3 mmol/L will be recruited from 3 West Midlands HIV services. Participants will be randomised 1:1 to 1 of 2 dietary interventions, with stratification by gender and smoking status. Participants allocated to Diet1 will receive advice to reduce saturated fat intake, and those to Diet2 on how to adopt the Mediterranean Portfolio Diet with additional cholesterol-lowering foods (nuts, stanols, soya, oats, pulses). Measurements of fasting blood lipids, body composition and arterial stiffness will be conducted at baseline, and month 6 and 12 of the intervention. Food intake will be assessed using the Mediterranean Diet Score, 3-day food diaries and metabolomic biomarkers. Questionnaires will be used to assess quality of life and process evaluation. Qualitative interviews will explore barriers and facilitators to making dietary changes, and participant views on the intervention. Qualitative data will be analysed using the Framework Method. Feasibility will be assessed in terms of trial recruitment, retention, compliance to study visits and the intervention. SD of outcomes will inform the power calculation of the definitive RCT.

ETHICS

The West Midlands Ethics Committee has approved this study and informed consent forms. This trial is the first to test cholesterol-lowering foods in adults with HIV.

TRIAL REGISTRATION NUMBER

ISRCTN32090191; Pre-results.

Estimated cardiovascular relative risk reduction from fixed-dose combination pill (polypill) treatment in a wide range of patients with a moderate risk of cardiovascular disease

AIMS

Recent data indicate that fixed-dose combination (FDC) pills, polypills, can produce sizeable risk factor reductions. There are very few published data on the consistency of the effects of a polypill in different patient populations. It is unclear for example whether the effects of the polypill are mainly driven by the individuals with high individual risk factor levels. The aim of the present study is to examine whether baseline risk factor levels modify the effect of polypill treatment on low-density lipoprotein (LDL)-cholesterol, blood pressure (BP), calculated cardiovascular relative risk reduction and adverse events.

METHODS

This paper describes a post-hoc analysis of a randomised, placebo-controlled trial of a polypill (containing aspirin 75 mg, simvastatin 20 mg, lisinopril 10 mg and hydrochlorothiazide 12.5 mg) in 378 individuals without an indication for any component of the polypill, but who had an estimated five-year risk for cardiovascular disease ≥7.5%. The outcomes considered were effect modification by baseline risk factor levels on change in LDL-cholesterol, systolic BP, calculated cardiovascular relative risk reduction and adverse events.

RESULTS

The mean LDL-cholesterol in the polypill group was 0.9 mmol/l (95% confidence interval (CI): 0.8-1.0) lower compared with the placebo group during follow-up. Those with a baseline LDL-cholesterol >3.6 mmol/l achieved a greater absolute LDL-cholesterol reduction with the polypill compared with placebo, than patients with an LDL-cholesterol ≤3.6 mmol/l (-1.1 versus -0.6 mmol/l, respectively). The mean systolic BP was 10 mm Hg (95% CI: 8-12) lower in the polypill group. In participants with a baseline systolic BP >135 mm Hg the polypill resulted in a greater absolute systolic BP reduction with the polypill compared with placebo, than participants with a systolic BP ≤ 135 mm Hg (-12 versus -7 mm Hg, respectively). Calculated from individual risk factor reductions, the mean cardiovascular relative risk reduction was 48% (95% CI: 43-52) in the polypill group. Both baseline LDL-cholesterol and estimated cardiovascular risk were significant modifiers of the estimated cardiovascular relative risk reduction caused by the polypill. Adverse events did not appear to be related to baseline risk factor levels or the estimated cardiovascular risk.

CONCLUSION

This study demonstrated that the effect of a cardiovascular polypill on risk factor levels is modified by the level of these risk factors. Groups defined by baseline LDL-cholesterol or systolic BP had large differences in risk factor reductions but only moderate differences in estimated cardiovascular relative risk reduction, suggesting also that patients with mildly increased risk factor levels but an overall raised cardiovascular risk benefit from being treated with a polypill.

Lessons learned from England's Health Checks Programme: using qualitative research to identify and share best practice

Background

This study aimed to explore the challenges and barriers faced by staff involved in the delivery of the National Health Service (NHS) Health Check, a systematic cardiovascular disease (CVD) risk assessment and management program in primary care.

Methods

Data have been derived from three qualitative evaluations that were conducted in 25 General Practices and involved in depth interviews with 58 staff involved all levels of the delivery of the Health Checks. Analysis of the data was undertaken using the framework approach and findings are reported within the context of research and practice considerations.

Results

Findings indicated that there is no ‘one size fits all’ blueprint for maximising uptake although success factors were identified: evolution of the programme over time in response to local needs to suit the particular characteristics of the patient population; individual staff characteristics such as being proactive, enthusiastic and having specific responsibility; a supportive team. Training was clearly identified as an area that needed addressing and practitioners would benefit from CVD specific baseline training and refresher courses to keep them up to date with recent developments in the area. However there were other external factors that impinged on an individual’s ability to provide an effective service, some of these were outside the control of individuals and included cutbacks in referral services, insufficient space to run clinics or general awareness of the Health Checks amongst patients.

Conclusions

The everyday experiences of practitioners who participated in this study suggest that overall, Health Check is perceived as a worthwhile exercise. But, organisational and structural barriers need to be addressed. We also recommend that clear referral pathways be in place so staff can refer patients to appropriate services (healthy eating sessions, smoking cessation, and exercise referrals). Local authorities need to support initiatives that enable data sharing and linkage so that GP Practices are informed when patients take up services such as smoking cessation or alcohol harm reduction programmes run by social services.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-015-0365-z) contains supplementary material, which is available to authorized users.

Should patients prescribed long-term low-dose aspirin receive proton pump inhibitors? A systematic review and meta-analysis

BACKGROUND

Several clinical guidelines recommend the use of proton pump inhibitors (PPIs) in patients taking low-dose aspirin but report no or limited supporting data. We conducted a systematic review and meta-analysis to examine the effects of co-administration of PPIs in patients taking low-dose aspirin on the risks of adverse gastrointestinal (GI) and cardiovascular (CV) events, and on patient adherence to aspirin.

METHODS

We searched PUBMED, EMBASE and Cochrane Central Register of Controlled Trials databases for relevant articles published through November 2013. We included randomised controlled trials (RCTs) and observational studies in patients taking low-dose aspirin with and without PPIs. Risk of bias was assessed using the Cochrane Collaboration's tool (for RCTs) and the Newcastle-Ottawa Scale (for observational studies). Pooled risk ratios (RRs) were computed using a random-effects model.

RESULTS

We included 13 studies, of which 12 (2 RCTs and 10 observational studies) reported on GI events, and one (cohort study) on both GI bleeding and CV events. No study reported on adherence to aspirin. Co-administration of PPIs in patients receiving low-dose aspirin was associated with risk reductions of 73% (RR 0.27, 95% CI 0.17-0.42) and 50% (RR 0.50, 95% CI 0.32-0.80) in the occurrence of peptic ulcer and GI bleeding respectively. There was evidence of bias in publications reporting on the GI events.

CONCLUSIONS

The practice of co-prescribing PPIs in patients taking low-dose aspirin is supported by some data, but the evidence is rather weak. It currently remains unclear whether the benefits of co-administration of PPIs in users of low-dose aspirin outweigh their potential harms.

Applicability of the Existing CVD Risk Assessment Tools to Type II Diabetics in Oman: A Review

Patients with type II diabetes (T2DM) have an elevated risk for cardiovascular disease (CVD), and it is considered to be a leading cause of morbidity and premature mortality in these patients. Many traditional risk factors such as age, male sex, hypertension, dyslipidemia, glycemic control, diabetes duration, renal dysfunction, obesity, and smoking have been studied and identified as independent factors for CVD. Quantifying the risk of CVD among diabetics using the common risk factors in order to plan the treatment and preventive measures is important in the management of these patients as recommended by many clinical guidelines. Therefore, several risk assessment tools have been developed in different parts of the world for this purpose. These include the tools that have been developed for general populations and considered T2DM as a risk factor, and the tools that have been developed for T2DM populations specifically. However, due to the differences in sociodemographic factors and lifestyle patterns, as well as the differences in the distribution of various CVD risk factors in different diabetic populations, the external applicability of these tools on different populations is questionable. This review aims to address the applicability of the existing CVD risk models to the Omani diabetic population.

The effectiveness of German disease management programs (DMPs) in patients with type 2 diabetes mellitus and coronary heart disease: results from an observational longitudinal study

BACKGROUND

Although the population-based German disease management programs (DMPs) for diabetes mellitus (DM) and coronary heart disease (CHD) are among the biggest worldwide, evidence on the effectiveness of these programs is still inconclusive or missing, particularly for high risk patients with comorbidities. The objective of this study was therefore to analyze the impact of DMPs on process and outcome parameters in patients with both, type 2 DM and CHD.

METHODS

Analyses are based on two postal surveys of patients from the KORA myocardial infarction registry (southern Germany) with type 2 DM and on two postal validation studies with patients' general physicians (2006, n = 312 and 2011, n = 212). The association between DMP enrollment (being enrolled in either DMP-DM or DMP-CHD) and guideline care (defined by several process indicators) at baseline (2006) and its development until follow-up (2011) was analyzed using logistic regression models accounting for the repeated measurements structure. The impact of DMP enrollment/guideline care on cumulated (quality-adjusted) life years ((QA)LYs) over a 4-year time horizon (2006-2010) was assessed using multiple linear regression methods. Logistic regression models were applied to analyze the association between DMP status and patient self-management at follow-up.

RESULTS

Being enrolled in a DMP was associated with better guideline care at baseline [OR = 2.3 (95 % CI 1.27-4.03)], but not at follow-up [OR = 0.80 (95 % CI 0.40-1.58); p value for time-interaction <0.01]. DMP enrollment was not significantly [+0.15 LYs (95 % CI -0.07, 0.37); +0.06 QALYs (95 % CI -0.15, 0.26)], but treatment according to guideline care significantly [+0.40 LYs (95 % CI 0.21-0.60); +0.28 QALYs (95 % CI 0.10-0.45)] associated with higher (quality-adjusted) survival over the 4-year follow-up period. DMP enrollees further reported a somewhat better self-management than patients not being enrolled into a DMP.

CONCLUSIONS

The results of this study concerning the effectiveness of DMPs in patients with DM and CHD are mixed, but are weakly in favor of DMPs. However, we found a clear positive impact of guideline care on quality adjusted survival in this patient group. The development of the association between DMP enrollment and guideline care over the follow-up time indicates some external effects, which should be the subject of further investigations.

Change in cardiovascular risk factors following early diagnosis of type 2 diabetes: a cohort analysis of a cluster-randomised trial

Background

There is little evidence to inform the targeted treatment of individuals found early in the diabetes disease trajectory.

Aim

To describe cardiovascular disease (CVD) risk profiles and treatment of individual CVD risk factors by modelled CVD risk at diagnosis; changes in treatment, modelled CVD risk, and CVD risk factors in the 5 years following diagnosis; and how these are patterned by socioeconomic status.

Design and setting

Cohort analysis of a cluster-randomised trial (ADDITION-Europe) in general practices in Denmark, England, and the Netherlands.

Method

A total of 2418 individuals with screen-detected diabetes were divided into quartiles of modelled 10-year CVD risk at diagnosis. Changes in treatment, modelled CVD risk, and CVD risk factors were assessed at 5 years.

Results

The largest reductions in risk factors and modelled CVD risk were seen in participants who were in the highest quartile of modelled risk at baseline, suggesting that treatment was offered appropriately. Participants in the lowest quartile of risk at baseline had very similar levels of modelled CVD risk at 5 years and showed the least variation in change in modelled risk. No association was found between socioeconomic status and changes in CVD risk factors, suggesting that treatment was equitable.

Conclusion

Diabetes management requires setting of individualised attainable targets. This analysis provides a reference point for patients, clinicians, and policymakers when considering goals for changes in risk factors early in the course of the disease that account for the diverse cardiometabolic profile present in individuals who are newly diagnosed with type 2 diabetes.

Risks for mortality and renal replacement therapy in atherosclerotic renovascular disease compared with other causes of chronic kidney disease

AIM

Patients with atherosclerotic renovascular disease (ARVD) have an increased risk for death and likelihood of initiating renal replacement therapy (RRT) compared with the general population. No data exist to describe prognosis in ARVD compared with other causes of chronic kidney disease (CKD). We compare patient outcomes between ARVD and other causes of CKD.

METHODS

Patients were selected from two prospective observational cohort studies of outcome in ARVD and CKD. Multivariate Cox regression was used to compare risk for RRT and death (both prior to and following initiation of RRT) between patients with ARVD and other causes of CKD.

RESULTS

Of 1472 patients (563 (38%) ARVD, 909 (62%) non-ARVD), 242 (16%) progressed to RRT and 640 (44%) died over a median follow-up period of 4.1 (2.4-5.6) years. Patients with ARVD had an increased risk for death (HR 1.5 (1.2-1.8), P < 0.001) but not for RRT (HR 1.0 (0.7-1.4), P = 0.9). The largest increase in risk for death was observed relative to renal limited diseases, e.g. pyelonephritis (HR 2.4 (1.3-4.5), P = 0.004) and interstitial/infiltrative disease (HR 2.2 (1.3-4.5), P = 0.02). Following initiation of RRT, patients with ARVD had a significantly increased risk for death compared with patients without ARVD (HR 3.3 (2.2-5.0), P < 0.001).

CONCLUSIONS

Patients with ARVD as a cause of CKD have an increased risk for death both prior to and following initiation of RRT. Further work should seek to identify modifiable risk factors relevant to prognosis.

The Heart Health Study - increasing cardiovascular risk assessment in family practice for first degree relatives of patients with premature ischaemic heart disease: a randomised controlled trial

BACKGROUND

This study aimed to increase cardiovascular disease (CVD) risk assessment in adult first degree relatives of patients with premature ischaemic heart disease (PIHD) using written and verbal advice.

METHODS

DESIGN

A prospective, randomised controlled trial.

SETTING

Cardiovascular wards at three South Australian hospitals. Cardiovascular risk assessments were performed in general practice.

PARTICIPANTS

Patients experiencing PIHD (heart disease in men aged <55 years or women aged < 65 years) and their first degree relatives.

INTERVENTION

Patients distributed either general information about heart disease and written advice to attend their general practitioner (GP) for CVD risk assessment or general information about heart disease only, to their first degrees relatives.

MAIN OUTCOME MEASURE

The primary outcome was the proportion of relatives who attended their GP for CVD risk assessment within 6 months of the patients' PIHD event.

RESULTS

One hundred forty four patients were recruited who had 541 eligible relatives; 97/541 (18 %) of relatives agreed to participate. A larger number of intervention 41/55 (75 %) than control group 9/42 (21 %) [difference 53 %, 95 % CI 36 % - 71 %] relatives attended their GP for a CVD assessment, and 34 % of these had moderate to very high 5-year absolute risk for CVD.

CONCLUSION

This low cost intervention demonstrates that individuals who have a family history of PIHD and are at moderate or high risk of CVD can be targeted for early intervention of modifiable risk factors. Further research is required to improve the uptake of the intervention in relatives.

TRIAL REGISTRATION

The trial was registered with the Australian Clinical Trials Registry (ACTRN), Registration ID 12613000557730 .

The value of aspartate aminotransferase and alanine aminotransferase in cardiovascular disease risk assessment

OBJECTIVE

Aspartate aminotransferase to alanine aminotransferase (AST/ALT) ratio, reflecting liver disease severity, has been associated with increased risk of cardiovascular disease (CVD). The aim of this study was to evaluate whether the AST/ALT ratio improves established risk prediction tools in a primary care population.

METHODS

Data were analysed from a prospective cohort of 29 316 UK primary care patients, aged 25-84 years with no history of CVD at baseline. Cox proportional hazards regression was used to derive 10-year multivariate risk models for the first occurrence of CVD based on two established risk prediction tools (Framingham and QRISK2), with and without including the AST/ALT ratio. Overall, model performance was assessed by discriminatory accuracy (AUC c-statistic).

RESULTS

During a total follow-up of 120 462 person-years, 782 patients (59% men) experienced their first CVD event. Multivariate models showed that elevated AST/ALT ratios were significantly associated with CVD in men (Framingham: HR 1.37, 95% CI 1.05 to 1.79; QRISK2: HR 1.40, 95% CI 1.04 to 1.89) but not in women (Framingham: HR 1.06, 95% CI 0.78 to 1.43; QRISK2: HR 0.97, 95% CI 0.70 to 1.35). Including the AST/ALT ratio with all Framingham risk factors (AUC c-statistic: 0.72, 95% CI 0.71 to 0.74) or QRISK2 risk factors (AUC c-statistic: 0.73, 95% CI 0.71 to 0.74) resulted in no change in discrimination from the established risk prediction tools. Limiting analysis to those individuals with raised ALT showed that discrimination could improve by 5% and 4% with Framingham and QRISK2 risk factors, respectively.

CONCLUSIONS

Elevated AST/ALT ratio is significantly associated with increased risk of developing CVD in men but not women. However, the ratio does not confer any additional benefits over established CVD risk prediction tools in the general population, but may have clinical utility in certain subgroups.

The mediation of coronary calcification in the association between risk scores and cardiac troponin T elevation in healthy adults: Is atherosclerosis a good prognostic precursor of coronary disease?

BACKGROUND

Conventional cardiac risk scores may not be completely accurate in predicting acute events because they only include factors associated with atherosclerosis, considered as the fundamental precursor of cardiovascular disease. In UK in 2006-2008 (Whitehall II study) we tested the ability of several risk scores to identify individuals with cardiac cell damage and assessed to what extent their estimates were mediated by the presence of atherosclerosis.

METHODS

430 disease-free, low-risk participants were tested for high-sensitivity cardiac troponin-T (HS-CTnT) and for coronary calcification using electron-beam, dual-source, computed tomography (CAC). We analysed the data cross-sectionally using ROC curves and mediation tests.

RESULTS

When the risk scores were ranked according to the magnitude of ROC areas for HS-CTnT prediction, a score based only on age and gender came first (ROC area=0.79), followed by Q-Risk2 (0.76), Framingham (0.70), Joint-British-Societies (0.69) and Assign (0.68). However, when the scores were ranked according to the extent of mediation by CAC (proportion of association mediated), their order was essentially reversed (age&gender=6.8%, Q-Risk2=9.7%, Framingham=16.9%, JBS=17.8%, Assign=17.7%). Therefore, the more accurate a score is in predicting detectable HS-CTnT, the less it is mediated by CAC; i.e. the more able a score is in capturing atherosclerosis the less it is able to predict cardiac damage. The P for trend was 0.009.

CONCLUSIONS

The dynamics through which cardiac cell damage is caused cannot be explained by 'classic' heart disease risk factors alone. Further research is needed to identify precursors of heart disease other than atherosclerosis.

Clinical Utility of a Coronary Heart Disease Risk Prediction Gene Score in UK Healthy Middle Aged Men and in the Pakistani Population

BACKGROUND

Numerous risk prediction algorithms based on conventional risk factors for Coronary Heart Disease (CHD) are available but provide only modest discrimination. The inclusion of genetic information may improve clinical utility.

METHODS

We tested the use of two gene scores (GS) in the prospective second Northwick Park Heart Study (NPHSII) of 2775 healthy UK men (284 cases), and Pakistani case-control studies from Islamabad/Rawalpindi (321 cases/228 controls) and Lahore (414 cases/219 controls). The 19-SNP GS included SNPs in loci identified by GWAS and candidate gene studies, while the 13-SNP GS only included SNPs in loci identified by the CARDIoGRAMplusC4D consortium.

RESULTS

In NPHSII, the mean of both gene scores was higher in those who went on to develop CHD over 13.5 years of follow-up (19-SNP p=0.01, 13-SNP p=7x10-3). In combination with the Framingham algorithm the GSs appeared to show improvement in discrimination (increase in area under the ROC curve, 19-SNP p=0.48, 13-SNP p=0.82) and risk classification (net reclassification improvement (NRI), 19-SNP p=0.28, 13-SNP p=0.42) compared to the Framingham algorithm alone, but these were not statistically significant. When considering only individuals who moved up a risk category with inclusion of the GS, the improvement in risk classification was statistically significant (19-SNP p=0.01, 13-SNP p=0.04). In the Pakistani samples, risk allele frequencies were significantly lower compared to NPHSII for 13/19 SNPs. In the Islamabad study, the mean gene score was higher in cases than controls only for the 13-SNP GS (2.24 v 2.34, p=0.04). There was no association with CHD and either score in the Lahore study.

CONCLUSION

The performance of both GSs showed potential clinical utility in European men but much less utility in subjects from Pakistan, suggesting that a different set of risk loci or SNPs may be required for risk prediction in the South Asian population.