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Wallace IR, McEvoy CT, Hunter SJ, Hamill LL, Ennis CN, Bell PM, Patterson CC, Woodside JV, Young IS, McKinley MC. Dose-response effect of fruit and vegetables on insulin resistance in people at high risk of cardiovascular disease: a randomized controlled trial. Diabetes Care 2013; 36:3888-96. [PMID: 24130354 PMCID: PMC3836143 DOI: 10.2337/dc13-0718] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The purpose of this randomized controlled trial was to investigate the dose-response effect of fruit and vegetable (F&V) intake on insulin resistance (IR) in people who are overweight and at high risk of cardiovascular disease (CVD). RESEARCH DESIGN AND METHODS A total of 105 participants (mean age 56 years) followed a 4-week washout diet (one to two portions of F&Vs per day). Ninety-two participants completed the washout and were randomized to receive one to two, four, or seven portions of F&Vs per day for 12 weeks. IR was assessed at the start and end of this 12-week period by the two-step euglycemic-hyperinsulinemic clamp. Compliance was monitored using a combination of 4-day food diaries and plasma biomarkers of F&V intake. RESULTS A total of 89 participants completed the study. Participants attained self-reported F&V intakes of 1.8, 3.8, and 7.0 portions per day (P < 0.001) per group. There was a significant linear increase in serum lutein status across the groups, indicating good compliance (P < 0.001), and body weight was maintained (P = 0.77). No significant difference was found between groups in terms of a change in measures of whole-body, peripheral, or hepatic IR or adiponectin multimers. CONCLUSIONS Increased consumption of F&Vs, as advocated in public-health advice, has no effect on IR in overweight individuals who are at high risk of CVD when body weight is maintained. Recent evidence from systematic reviews indicates that particular classes or types of F&Vs may have particular antidiabetic properties; hence, it is possible that benefits may only be observed in response to a more specific fruit or vegetable intervention.
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152
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Reynolds TM. Targeted lipid treatment: decades of failure suggest new targets are in order. Int J Clin Pract 2013; 67:1214-6. [PMID: 24246200 DOI: 10.1111/ijcp.12240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- T M Reynolds
- Clinical Chemistry Department, Queens Hospital, Burton-on-Trent, UK.
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153
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Jameson K, Amber V, D'Oca K, Mills D, Giles A, Ambegaonkar B. Impact of lipid-lowering therapy on the prevalence of dyslipidaemia in patients at high-risk of cardiovascular events in UK primary care - a retrospective database study. Int J Clin Pract 2013; 67:1228-37. [PMID: 23944233 PMCID: PMC4232237 DOI: 10.1111/ijcp.12238] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Accepted: 06/22/2013] [Indexed: 01/14/2023] Open
Abstract
AIMS To estimate the prevalence of dyslipidaemias in high-risk patients new to lipid-modifying therapy (LMT), and establish the extent to which these lipid abnormalities are addressed by treatment in UK clinical practice. METHODS The PRIMULA study was a retrospective analysis, conducted using the UK General Practice Research Database. Two periods were studied as follows: a pretreatment period, defined as the 12 months before initiation of LMT (the index date), and a follow-up period of at least 12 months. Patients included in the study (n = 25,011) had dyslipidaemia with at least one abnormal lipid measurement [total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) or triglycerides (TG)] in the pretreatment period. All patients were at high risk of cardiovascular events, which was defined as having a history of cardiovascular disease, a 10-year Framingham risk score higher than 20%, diabetes or hypertension, as defined by the Joint British Societies 2 guidelines. RESULTS At the index date, 98% of patients were initiated on statin monotherapy. After 12 months of treatment, 15.2% (sub-group range: 11.0-22.9%) of all high-risk patients had no lipid abnormalities. The proportions of patients with high TC or LDL-C levels decreased from 98.8% to 68.9%, and from 99.2% to 68.7%, respectively, over 12 months. The prevalence of high TG levels decreased from 45.0% to 26.9%, whereas that of low HDL-C levels increased, from 16.6% to 18.0%. Risk factors for cardiovascular events were not consistently associated with the likelihood of attaining optimal lipid levels. CONCLUSIONS Despite widespread use of statins, many individuals at high risk of cardiovascular events have persistently abnormal lipid levels, with over two-thirds of patients not achieving target levels of LDL-C or TC. Management of dyslipidaemia is therefore suboptimal in this important high-risk group in UK standard practice.
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154
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M'Buyamba-Kabangu JR, Anisiuba BC, Ndiaye MB, Lemogoum D, Jacobs L, Ijoma CK, Thijs L, Boombhi HJ, Kaptue J, Kolo PM, Mipinda JB, Osakwe CE, Odili A, Ezeala-Adikaibe B, Kingue S, Omotoso BA, Ba SA, Ulasi II, Staessen JA. Efficacy of newer versus older antihypertensive drugs in black patients living in sub-Saharan Africa. J Hum Hypertens 2013; 27:729-35. [PMID: 23803591 PMCID: PMC3831294 DOI: 10.1038/jhh.2013.56] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 05/06/2013] [Accepted: 05/31/2013] [Indexed: 11/09/2022]
Abstract
To address the epidemic of hypertension in blacks born and living in sub-Saharan Africa, we compared in a randomised clinical trial (NCT01030458) single-pill combinations of old and new antihypertensive drugs in patients (30-69 years) with uncomplicated hypertension (140-179/90-109 mm Hg). After ≥4 weeks off treatment, 183 of 294 screened patients were assigned to once daily bisoprolol/hydrochlorothiazide 5/6.25 mg (n=89; R) or amlodipine/valsartan 5/160 mg (n=94; E) and followed up for 6 months. To control blood pressure (<140/<90 mm Hg), bisoprolol and amlodipine could be doubled (10 mg per day) and α-methyldopa (0.5-2 g per day) added. Sitting blood pressure fell by 19.5/12.0 mm Hg in R patients and by 24.8/13.2 mm Hg in E patients and heart rate decreased by 9.7 beats per minute in R patients with no change in E patients (-0.2 beats per minute). The between-group differences (R minus E) were 5.2 mm Hg (P<0.0001) systolic, 1.3 mm Hg (P=0.12) diastolic, and 9.6 beats per minute (P<0.0001). In 57 R and 67 E patients with data available at all visits, these estimates were 5.5 mm Hg (P<0.0001) systolic, 1.8 mm Hg (P=0.07) diastolic and 9.8 beats per minute (P<0.0001). In R compared with E patients, 45 vs 37% (P=0.13) proceeded to the higher dose of randomised treatment and 33 vs 9% (P<0.0001) had α-methyldopa added. There were no between-group differences in symptoms except for ankle oedema in E patients (P=0.012). In conclusion, new compared with old drugs lowered systolic blood pressure more and therefore controlled hypertension better in native African black patients.
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Affiliation(s)
- J R M'Buyamba-Kabangu
- Studies Coordinating Centre, Division of Hypertension and Cardiovascular Rehabilitation, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
- Hypertension Unit, Department of Internal Medicine, University of Kinshasa Hospital, Kinshasa, Democratic Republic of Congo
| | - B C Anisiuba
- Department of Medicine, College of Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - M B Ndiaye
- Centre Hospitalier National Aristide Le Dantec, Dakar, Senegal
| | - D Lemogoum
- Douala Cardiovascular Research Institute, Douala School of Medicine, Douala, Cameroon
| | - L Jacobs
- Studies Coordinating Centre, Division of Hypertension and Cardiovascular Rehabilitation, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - C K Ijoma
- Department of Medicine, College of Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - L Thijs
- Studies Coordinating Centre, Division of Hypertension and Cardiovascular Rehabilitation, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | | | - J Kaptue
- Douala Cardiovascular Research Institute, Douala School of Medicine, Douala, Cameroon
| | - P M Kolo
- Department of Medicine, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - J B Mipinda
- Centre Hospitalier de Libreville, Libreville, Gabon
| | - C E Osakwe
- Studies Coordinating Centre, Division of Hypertension and Cardiovascular Rehabilitation, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
- National Biotechnology Development Agency, Medical Biotechnology Department, Abuja, Nigeria
| | - A Odili
- Studies Coordinating Centre, Division of Hypertension and Cardiovascular Rehabilitation, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
- Department of Internal Medicine, College of Health Science, University of Abuja, Abuja, Nigeria
| | - B Ezeala-Adikaibe
- Department of Medicine, College of Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - S Kingue
- Yaoundé General Hospital, Yaoundé, Cameroon
| | - B A Omotoso
- Department of Medicine, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - S A Ba
- Centre Hospitalier National Aristide Le Dantec, Dakar, Senegal
| | - I I Ulasi
- Department of Medicine, College of Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - J A Staessen
- Studies Coordinating Centre, Division of Hypertension and Cardiovascular Rehabilitation, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
- Department of Epidemiology, Maastricht University, Maastricht, The Netherlands
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155
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Velmurugan S, Kapil V, Ghosh SM, Davies S, McKnight A, Aboud Z, Khambata RS, Webb AJ, Poole A, Ahluwalia A. Antiplatelet effects of dietary nitrate in healthy volunteers: involvement of cGMP and influence of sex. Free Radic Biol Med 2013; 65:1521-1532. [PMID: 23806384 PMCID: PMC3878381 DOI: 10.1016/j.freeradbiomed.2013.06.031] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Revised: 06/02/2013] [Accepted: 06/18/2013] [Indexed: 11/25/2022]
Abstract
Ingestion of vegetables rich in inorganic nitrate has emerged as an effective method, via the formation of a nitrite intermediate, for acutely elevating vascular NO levels. As such a number of beneficial effects of dietary nitrate ingestion have been demonstrated including the suggestion that platelet reactivity is reduced. In this study we investigated whether inorganic nitrate supplementation might also reduce platelet reactivity in healthy volunteers and have determined the mechanisms involved in the effects seen. We conducted two randomised crossover studies each in 24 (12 of each sex) healthy subjects assessing the acute effects of dietary nitrate (250 ml beetroot juice) or potassium nitrate capsules (KNO3, 8 mmol) vs placebo control on platelet reactivity. Inorganic nitrate ingested either from a dietary source or via supplementation raised circulating nitrate and nitrite levels in both sexes and attenuated ex vivo platelet aggregation responses to ADP and, albeit to a lesser extent, collagen but not epinephrine in male but not female volunteers. These inhibitory effects were associated with a reduced platelet P-selectin expression and elevated platelet cGMP levels. In addition, we show that nitrite reduction to NO occurs at the level of the erythrocyte and not the platelet. In summary, our results demonstrate that inorganic nitrate ingestion, whether via the diet or through supplementation, causes a modest decrease in platelet reactivity in healthy males but not females. Our studies provide strong support for further clinical trials investigating the potential of dietary nitrate as an adjunct to current antiplatelet therapies to prevent atherothrombotic complications. Moreover, our observations highlight a previously unknown sexual dimorphism in platelet reactivity to NO and intimate a greater dependence of males on the NO-soluble guanylate cyclase pathway in limiting thrombotic potential.
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Affiliation(s)
- Shanti Velmurugan
- Centre of Clinical Pharmacology, William Harvey Research Institute, Barts NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ
| | - Vikas Kapil
- Centre of Clinical Pharmacology, William Harvey Research Institute, Barts NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ
| | - Suborno M Ghosh
- Centre of Clinical Pharmacology, William Harvey Research Institute, Barts NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ
| | - Sheridan Davies
- Centre of Clinical Pharmacology, William Harvey Research Institute, Barts NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ
| | - Andrew McKnight
- Centre of Clinical Pharmacology, William Harvey Research Institute, Barts NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ
| | - Zainab Aboud
- Centre of Clinical Pharmacology, William Harvey Research Institute, Barts NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ
| | - Rayomand S Khambata
- Centre of Clinical Pharmacology, William Harvey Research Institute, Barts NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ
| | - Andrew J Webb
- Centre of Clinical Pharmacology, William Harvey Research Institute, Barts NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ
| | - Alastair Poole
- School of Physiology and Pharmacology, University of Bristol, Medical Sciences Building, University Walk, Bristol BS8 1TD, UK
| | - Amrita Ahluwalia
- Centre of Clinical Pharmacology, William Harvey Research Institute, Barts NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ.
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156
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Sussman J, Vijan S, Hayward R. Using benefit-based tailored treatment to improve the use of antihypertensive medications. Circulation 2013; 128:2309-17. [PMID: 24190955 DOI: 10.1161/circulationaha.113.002290] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Current guidelines for prescribing antihypertensive medications focus on reaching specific blood pressure targets. We sought to determine whether antihypertensive medications could be used more effectively by a treatment strategy based on tailored estimates of cardiovascular disease events prevented. METHODS AND RESULTS We developed a nationally representative sample of American adults aged 30 to 85 years with no history of myocardial infarction, stroke, or severe congestive heart failure using the National Health and Nutrition Examination Survey III. We then created a simulation model to estimate the effects of 5 years of treatment with treat-to-target (treatment to specific blood pressure goals) and benefit-based tailored treatment (treatment based on estimated cardiovascular disease event reduction) approaches to antihypertensive medication management. All effect size estimates were derived directly from meta-analyses of randomized trials. We found that 55% of the overall population of 176 million Americans would be treated identically under the 2 treatment approaches. Benefit-based tailored treatment would prevent 900 000 more cardiovascular disease events and save 2.8 million more quality-adjusted life-years, despite using 6% fewer medications over 5 years. In the 45% of the population treated differently by the strategies, benefit-based tailored treatment would save 159 quality-adjusted life-years per 1000 treated versus 74 quality-adjusted life-years per 1000 treated by the treat-to-target approach. The findings were robust to sensitivity analyses. CONCLUSIONS We found that benefit-based tailored treatment was both more effective and required less antihypertensive medication than current guidelines based on treating to specific blood pressure goals.
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Affiliation(s)
- Jeremy Sussman
- Division of General Internal Medicine, University of Michigan (J.S., S.V., R.H.), and the Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI (J.S., S.V., R.H.)
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157
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Stauffer ME, Weisenfluh L, Morrison A. Association between triglycerides and cardiovascular events in primary populations: a meta-regression analysis and synthesis of evidence. Vasc Health Risk Manag 2013; 9:671-80. [PMID: 24204156 PMCID: PMC3818028 DOI: 10.2147/vhrm.s52713] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Triglyceride levels were found to be independently predictive of the development of primary coronary heart disease in epidemiologic studies. The objective of this study was to determine whether triglyceride levels were predictive of cardiovascular events in randomized controlled trials (RCTs) of lipid-modifying drugs. Methods We performed a systematic review and meta-regression analysis of 40 RCTs of lipid-modifying drugs with cardiovascular events as an outcome. The log of the rate ratio of cardiovascular events (eg, coronary death or myocardial infarction) was plotted against the proportional difference between treatment and control groups in triglyceride and other lipid levels (high density lipoprotein cholesterol [HDL-C], low density lipoprotein cholesterol [LDL-C], and total cholesterol) for all trials and for trials of primary and secondary prevention populations. Linear regression was used to determine the statistical significance of the relationship between lipid values and cardiovascular events. Results The proportional difference in triglyceride levels was predictive of cardiovascular events in all trials (P=0.005 for the slope of the regression line; N=40) and in primary prevention trials (P=0.010; N=11), but not in secondary prevention trials (P=0.114; N=25). The proportional difference in HDL-C was not predictive of cardiovascular events in all trials (P=0.822; N=40), or in trials of primary (P=0.223; N=11) or secondary (P=0.487; N=25) prevention. LDL-C levels were predictive of cardiovascular events in both primary (P=0.002; N=11) and secondary (P<0.001; N=25) populations. Conclusions Changes in triglyceride levels were predictive of cardiovascular events in RCTs. This relationship was significant in primary prevention populations but not in secondary prevention populations.
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158
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Goh LGH, Dhaliwal SS, Lee AH, Bertolatti D, Della PR. Utility of established cardiovascular disease risk score models for the 10-year prediction of disease outcomes in women. Expert Rev Cardiovasc Ther 2013; 11:425-35. [PMID: 23570356 DOI: 10.1586/erc.13.26] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Cardiovascular disease (CVD) is a major cause of mortality globally. In absolute numbers, more women die from CVD than men do. CVD mortality risk differs between genders, reflecting the different distribution of modifiable risk factors and severity of CVD outcomes. This study reviews six established risk score models and their applicability to the female population. These models are assessed against two criteria: discrimination and calibration. Sensitivity, specificity and positive- and negative-predictive values are also examined. The risk score models are found to be limited in applicability, requiring recalibration beyond their study population. Relevant risk factors to predict CVD mortality for women, such as measures of obesity, physical activity, alcohol consumption, use of antihypertensive medication, chronic kidney disease and coronary artery calcium are generally not incorporated in these models.
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Affiliation(s)
- Louise G H Goh
- School of Public Health, Curtin Health Innovation Research Institute, Curtin University, GPO Box U 1987, Perth, WA 6845, Australia
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159
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Matera MG, Calzetta L, Cazzola M. β-Adrenoceptor Modulation in Chronic Obstructive Pulmonary Disease: Present and Future Perspectives. Drugs 2013; 73:1653-63. [DOI: 10.1007/s40265-013-0120-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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160
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Monk HL, Muller S, Mallen CD, Hider SL. Cardiovascular screening in rheumatoid arthritis: a cross-sectional primary care database study. BMC FAMILY PRACTICE 2013; 14:150. [PMID: 24106825 PMCID: PMC3851828 DOI: 10.1186/1471-2296-14-150] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 10/09/2013] [Indexed: 01/08/2023]
Abstract
Background Patients with rheumatoid arthritis (RA) are known to be at increased risk of vascular disease. It is not known whether screening for vascular risk factors occurs in primary care. The aim of this study was to determine whether guidance advocating cardiovascular screening in RA patients is being implemented in primary care. Methods This study was undertaken in a UK primary care consultation database. All patients with a diagnosis of RA between 2000 and 2008, and still registered with the GP practice in 2009 were matched by age, gender and GP practice to three non-RA patients. Evidence of screening for five traditional vascular risk factors (blood pressure, lipids, glucose, weight, smoking) was compared in those with and without RA using logistic regression models. A comparison was also made with diabetes. Results 401 RA patients were identified and matched to 1198 non-RA patients. No differences in the overall rates of screening were found (all five risk factors: RA 24.9% vs no RA 25.6%), but RA patients were more likely to have a smoking status recorded (67% versus 62%). In contrast, those with diabetes were up to 12 times as likely to receive vascular screening. Conclusions Despite the excess risk of vascular disease in patients with RA being of a similar magnitude to that seen in diabetes, patients with RA did not receive additional CVD screening in primary care, although this was achieved in patients with diabetes. More emphasis needs to be placed on ensuring those with RA are actively screened for cardiovascular disease in primary care.
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Affiliation(s)
- Helen L Monk
- Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele, UK.
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161
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A randomised controlled trial evaluating the effect of potassium supplementation on vascular function and the renin-angiotensin-aldosterone system. J Hum Hypertens 2013; 28:333-9. [PMID: 24048291 DOI: 10.1038/jhh.2013.89] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 07/22/2013] [Accepted: 08/19/2013] [Indexed: 12/19/2022]
Abstract
There is limited evidence on the effect of potassium supplementation on the vasculature in patients at increased cardiovascular risk. Potassium increases aldosterone and there is a strong association of hyperaldosteronism with poor cardiac outcomes. We aimed to determine whether potassium supplementation has a significant medium-term effect on aldosterone levels and, if so, what the overall effect of this is on vascular function in patients at moderate cardiovascular disease risk. Forty patients at moderate cardiovascular disease risk were included in a randomised placebo-controlled crossover study. Patients were assigned to 64 mmol potassium chloride or placebo for 6 weeks. Vascular function was assessed using pulse-wave analysis including the detection of a change in augmentation index to salbutamol and nitroglycerine-induced vasodilation. There was no change in augmentation index with potassium vs placebo (25.2±1.4 vs. 26.0±1.3%, respectively). Potassium improved brachial systolic blood pressure (131.8±2.2 vs. 137.1±2.4 mm Hg; P=0.013), central systolic blood pressure (123.2±2.3 vs. 128.4±2.3 mm Hg; P=0.011) and central diastolic blood pressure (80.3±1.3 vs. 83.7±1.4 mm Hg; P=0.019). Plasma renin activity and serum aldosterone both increased with potassium (P=0.001 and P=0.048 respectively). We found that potassium supplementation had no effect on endothelial function or pulse-wave analysis. It lowered brachial systolic and central blood pressure. It was associated with increased plasma renin activity and serum aldosterone.
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162
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Armah CN, Traka MH, Dainty JR, Defernez M, Janssens A, Leung W, Doleman JF, Potter JF, Mithen RF. A diet rich in high-glucoraphanin broccoli interacts with genotype to reduce discordance in plasma metabolite profiles by modulating mitochondrial function. Am J Clin Nutr 2013; 98:712-22. [PMID: 23964055 PMCID: PMC3743733 DOI: 10.3945/ajcn.113.065235] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Accepted: 06/07/2013] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Observational and experimental studies suggest that diets rich in cruciferous vegetables and glucosinolates may reduce the risk of cancer and cardiovascular disease (CVD). OBJECTIVE We tested the hypothesis that a 12-wk dietary intervention with high-glucoraphanin (HG) broccoli would modify biomarkers of CVD risk and plasma metabolite profiles to a greater extent than interventions with standard broccoli or peas. DESIGN Subjects were randomly assigned to consume 400 g standard broccoli, 400 g HG broccoli, or 400 g peas each week for 12 wk, with no other dietary restrictions. Biomarkers of CVD risk and 347 plasma metabolites were quantified before and after the intervention. RESULTS No significant differences in the effects of the diets on biomarkers of CVD risk were found. Multivariate analyses of plasma metabolites identified 2 discrete phenotypic responses to diet in individuals within the HG broccoli arm, differentiated by single nucleotide polymorphisms associated with the PAPOLG gene. Univariate analysis showed effects of sex (P < 0.001), PAPOLG genotype (P < 0.001), and PAPOLG genotype × diet (P < 0.001) on the plasma metabolic profile. In the HG broccoli arm, the consequence of the intervention was to reduce variation in lipid and amino acid metabolites, tricarboxylic acid (TCA) cycle intermediates, and acylcarnitines between the 2 PAPOLG genotypes. CONCLUSIONS The metabolic changes observed with the HG broccoli diet are consistent with a rebalancing of anaplerotic and cataplerotic reactions and enhanced integration of fatty acid β-oxidation with TCA cycle activity. These modifications may contribute to the reduction in cancer risk associated with diets that are rich in cruciferous vegetables. This trial was registered at clinicaltrials.gov as NCT01114399.
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Affiliation(s)
- Charlotte N Armah
- Food and Health Programme, Institute of Food Research, Norwich Research Park, Norwich, United Kingdom
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163
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Khavandi K, Amer H, Ibrahim B, Brownrigg J. Strategies for preventing type 2 diabetes: an update for clinicians. Ther Adv Chronic Dis 2013; 4:242-61. [PMID: 23997928 PMCID: PMC3752182 DOI: 10.1177/2040622313494986] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Diabetes is a major and growing public health challenge which threatens to overwhelm medical services in the future. Type 2 diabetes confers significant morbidity and mortality, most notably with target organ damage to the eyes, kidneys, nerves and heart. The magnitude of cardiovascular risk associated with diabetes is best illustrated by its position as a coronary heart disease risk equivalent. Complications related to neuropathy are also vast, often working in concert with vascular abnormalities and resulting in serious clinical consequences such as foot ulceration. Increased understanding of the natural history of this disorder has generated the potential to intervene and halt pathological progression before overt disease ensues, after which point management becomes increasingly challenging. The concept of prediabetes as a formal diagnosis has begun to be translated from the research setting to clinical practice, but with continually updated guidelines, varied nomenclature, emerging pharmacotherapies and an ever-changing evidence base, clinicians may be left uncertain of best practice in identifying and managing patients at the prediabetic stage. This review aims to summarize the epidemiological data, new concepts in disease pathogenesis and guideline recommendations in addition to lifestyle, pharmacological and surgical therapies targeted at stopping progression of prediabetes to diabetes. While antidiabetic medications, with newer anti-obesity medications and interventional bariatric procedures have shown some promising benefits, diet and therapeutic lifestyle change remains the mainstay of management to improve the metabolic profile of individuals with glucose dysregulation. New risk stratification tools to identify at-risk individuals, coupled with unselected population level intervention hold promise in future practice.
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Affiliation(s)
- Kaivan Khavandi
- BHF Centre of Excellence in Cardiovascular Research, The Rayne Institute, Department of Cardiology, King's College London, St Thomas' Hospital, Westminster Palace Road, London SE1 7EH, UK
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164
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Artac M, Dalton ARH, Majeed A, Car J, Huckvale K, Millett C. Uptake of the NHS Health Check programme in an urban setting. Fam Pract 2013; 30:426-35. [PMID: 23377607 PMCID: PMC3722503 DOI: 10.1093/fampra/cmt002] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The NHS Health Check programme aims to improve prevention, early diagnosis and management of cardiovascular disease (CVD) in England. High and equitable uptake is essential for the programme to effectively reduce the CVD burden. OBJECTIVES Assessing the impact of a local financial incentive scheme on uptake and statin prescribing in the first 2 years of the programme. METHODS Cross-sectional study using data from electronic medical records of general practices in Hammersmith and Fulham, London on all patients aged 40-74 years. We assessed uptake of complete Health Check, exclusion of patients from the programme (exception reporting) and statin prescriptions in patients confirmed with high CVD risk. RESULTS The Health Check uptake was 32.7% in Year 1 and 20.0% in Year 2. Older patients had higher uptake of Health Check than younger (65- to 74-year-old patients: Year 1 adjusted odds ratio (AOR) 2.05 (1.67-2.52) & Year 2 AOR 2.79 (2.49-3.12) compared with 40- to 54-year-old patients). The percentage of confirmed high risk patients prescribed a statin was 17.7% before and 52.9% after the programme. There was a marked variation in Health Check uptake, exception reporting and statin prescribing between practices. CONCLUSIONS Uptake of the Health Check was low in the first year in patients with estimated high risk despite financial incentives to general practices; although this matched the national required rate in second year. Further evaluations for cost and clinical effectiveness of the programme are needed to clarify whether this spending is appropriate, and to assess the impact of financial incentives on programme performance.
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Affiliation(s)
- Macide Artac
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, 3rd Floor, Reynolds Building, St. Dunstan's Road, London W6 8RP, UK.
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165
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Wu J, Zhu S, Yao GL, Mohammed MA, Marshall T. Patient factors influencing the prescribing of lipid lowering drugs for primary prevention of cardiovascular disease in UK general practice: a national retrospective cohort study. PLoS One 2013; 8:e67611. [PMID: 23922649 PMCID: PMC3724846 DOI: 10.1371/journal.pone.0067611] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 05/24/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Guidelines indicate eligibility for lipid lowering drugs, but it is not known to what extent GPs' follow guidelines in routine clinical practice or whether additional clinical factors systematically influence their prescribing decisions. METHODS A retrospective cohort analysis was undertaken using electronic primary care records from 421 UK general practices. At baseline (May 2008) patients were aged 30 to 74 years, free from cardiovascular disease and not taking lipid lowering drugs. The outcome was prescription of a lipid lowering drug within the next two years. The proportions of eligible and ineligible patients prescribed lipid lowering drugs were reported and multivariable logistic regression models were used to investigate associations between age, sex, cardiovascular risk factors and prescribing. RESULTS Of 365,718 patients with complete data, 13.8% (50,558) were prescribed lipid lowering drugs: 28.5% (21,101/74,137) of those eligible and 10.1% (29,457/291,581) of those ineligible. Only 41.7% (21,101/50,558) of those prescribed lipid lowering drugs were eligible. In multivariable analysis prescribing was most strongly associated with increasing age (OR for age ≥ 65 years 4.21; 95% CI 4.05-4.39); diabetes (OR 4.49; 95% CI 4.35-4.64); total cholesterol level ≥ 7 mmol/L (OR 2.20; 95% CI 2.12-2.29); and ≥ 4 blood pressure measurements in the past year (OR 4.24; 95% CI 4.06-4.42). The predictors were similar in eligible and ineligible patients. CONCLUSIONS Most lipid lowering drugs for primary prevention are prescribed to ineligible patients. There is underuse of lipid lowering drugs in eligible patients.
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Affiliation(s)
- Jianhua Wu
- Centre for Environmental and Preventive Medicine, Barts and The London School of Medicine and Dentistry, University of London, London, United Kingdom
| | - Shihua Zhu
- School of Public Health and Population Science, University of Birmingham, Birmingham, United Kingdom
| | - Guiqing Lily Yao
- Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton, United Kingdom
| | - Mohammed A. Mohammed
- School of Public Health and Population Science, University of Birmingham, Birmingham, United Kingdom
| | - Tom Marshall
- School of Public Health and Population Science, University of Birmingham, Birmingham, United Kingdom
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166
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Hasanaj Q, Wilson BJ, Little J, Montazeri Z, Carroll JC. Family history: impact on coronary heart disease risk assessment beyond guideline-defined factors. Public Health Genomics 2013; 16:208-14. [PMID: 23886802 DOI: 10.1159/000353460] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 06/03/2013] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Family history (FH) provides insights into the effects of shared genomic susceptibilities, environments and behaviors, making it a potentially valuable risk assessment tool for chronic diseases. We assessed whether coronary heart disease (CHD) risk assessment is improved when FH information is added to other clinical information recommended in guidelines. METHODS We applied logistic regression analyses to cross-sectional data originally obtained from a UK study of women who delivered a live-born infant between 1951 and 1970. We developed 3 models: Model 1 included only the covariates in a guideline applicable to the population, Model 2 added FH to Model 1, and Model 3 included a fuller range of risk factors. For each model, its ability to discriminate between study subjects with and those without CHD was evaluated and its impact on risk classification examined using the net reclassification index. RESULTS FH was an independent risk factor for CHD (odds ratio = 1.7, 95% confidence interval = 1.26-2.47) and improved discrimination beyond guideline-defined clinical factors (p < 0.0006). However, the difference in the area under the curve of 2.8% and the extent of patient reclassification resulting from the inclusion of FH were small (p = 0.11). CONCLUSION While FH were a significant independent risk factor for CHD, it added little to risk factors typically included in guidelines.
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Affiliation(s)
- Q Hasanaj
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ont., Canada
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168
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Sayin MR, Cetiner MA, Karabag T, Akpinar I, Sayin E, Kurcer MA, Dogan SM, Aydin M. Framingham risk score and severity of coronary artery disease. Herz 2013; 39:638-43. [PMID: 23873009 DOI: 10.1007/s00059-013-3881-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Revised: 06/11/2013] [Accepted: 06/12/2013] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Coronary artery disease (CAD) is a leading cause of morbidity and mortality worldwide. Easy-to-perform and reliable parameters are needed to predict the presence and severity of CAD and to implement efficient diagnostic and therapeutic modalities. We aimed to examine whether the Framingham risk scoring system can be used for this purpose. METHODS A total of 222 patients (96 women, 126 men; mean age, 59.1 ± 11.9 years) who underwent coronary angiography were enrolled in the study. Presence of > %50 stenosis in a coronary artery was assessed as critical CAD. The Framingham risk score (FRS) was calculated for each patient. CAD severity was assessed by the Gensini score. The relationship between the FRS and the Gensini score was analyzed by correlation and regression analyses. RESULTS The mean Gensini score was 18.9 ± 25.8, the median Gensini score was 7.5 (0-172), the mean FRS was 7.7 ± 4.2, and the median FRS was 7 (0-21). Correlation analysis revealed a significant relationship between FRS and Gensini score (r = 0.432, p < 0.0001). This relationship was confirmed by linear regression analysis (β = 0.341, p < 0.0001). A cut-off level of 7.5 for FRS predicted severe CAD with a sensitivity of 68 % and a specificity of 73.6 % (ROC area under curve: 0.776, 95 % CI: 0.706-0.845, PPV: 78.1 %, NPV: 62.3 %, p < 0.0001). CONCLUSION Our work suggests that the FRS system is a simple and feasible method that can be used for prediction of CAD severity. As the sample size was small in our study, further large-scale studies are needed on this subject to draw solid conclusions.
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Affiliation(s)
- M R Sayin
- Department of Cardiology, Faculty of Medicine, Bulent Ecevit University, 67600, Kozlu/Zonguldak, Turkey,
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Keller H, Hirsch O, Kaufmann-Kolle P, Krones T, Becker A, Sönnichsen AC, Baum E, Donner-Banzhoff N. Evaluating an implementation strategy in cardiovascular prevention to improve prescribing of statins in Germany: an intention to treat analysis. BMC Public Health 2013; 13:623. [PMID: 23819600 PMCID: PMC3716622 DOI: 10.1186/1471-2458-13-623] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 04/30/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The prescription of statins is an evidence-based treatment to reduce the risk of cardiovascular events in patients with elevated cardiovascular risk or with a cardiovascular disorder (CVD). In spite of this, many of these patients do not receive statins. METHODS We evaluated the impact of a brief educational intervention in cardiovascular prevention in primary care physicians' prescribing behaviour regarding statins beyond their participation in a randomised controlled trial (RCT). For this, prescribing data of all patients > 35 years who were counselled before and after the study period were analysed (each n > 75,000). Outcome measure was prescription of Hydroxymethylglutaryl-CoA Reductase Inhibitors (statins) corresponding to patients' overall risk for CVD. Appropriateness of prescribing was examined according to different risk groups based on the Anatomical Therapeutic Chemical Classification System (ATC codes). RESULTS There was no consistent association between group allocation and statin prescription controlling for risk status in each risk group before and after study participation. However, we found a change to more significant drug configurations predicting the prescription of statins in the intervention group, which can be regarded as a small intervention effect. CONCLUSION Our results suggest that an active implementation of a brief evidence-based educational intervention does not lead to prescription modifications in everyday practice. Physician's prescribing behaviour is affected by an established health care system, which is not easy to change. TRIAL REGISTRATION ISRCTN71348772.
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Affiliation(s)
| | - Oliver Hirsch
- Department of General Practice/Family Medicine, Philipps University of Marburg, Karl-von-Frisch-Strasse 4, Marburg, 35043, Germany.
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den Ruijter HM, Peters SAE, Groenewegen KA, Anderson TJ, Britton AR, Dekker JM, Engström G, Eijkemans MJ, Evans GW, de Graaf J, Grobbee DE, Hedblad B, Hofman A, Holewijn S, Ikeda A, Kavousi M, Kitagawa K, Kitamura A, Koffijberg H, Ikram MA, Lonn EM, Lorenz MW, Mathiesen EB, Nijpels G, Okazaki S, O'Leary DH, Polak JF, Price JF, Robertson C, Rembold CM, Rosvall M, Rundek T, Salonen JT, Sitzer M, Stehouwer CDA, Witteman JC, Moons KG, Bots ML. Common carotid intima-media thickness does not add to Framingham risk score in individuals with diabetes mellitus: the USE-IMT initiative. Diabetologia 2013; 56:1494-502. [PMID: 23568273 PMCID: PMC4523149 DOI: 10.1007/s00125-013-2898-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 03/08/2013] [Indexed: 12/30/2022]
Abstract
AIMS/HYPOTHESIS The aim of this work was to investigate whether measurement of the mean common carotid intima-media thickness (CIMT) improves cardiovascular risk prediction in individuals with diabetes. METHODS We performed a subanalysis among 4,220 individuals with diabetes in a large ongoing individual participant data meta-analysis involving 56,194 subjects from 17 population-based cohorts worldwide. We first refitted the risk factors of the Framingham heart risk score on the individuals without previous cardiovascular disease (baseline model) and then expanded this model with the mean common CIMT (CIMT model). The absolute 10 year risk for developing a myocardial infarction or stroke was estimated from both models. In individuals with diabetes we compared discrimination and calibration of the two models. Reclassification of individuals with diabetes was based on allocation to another cardiovascular risk category when mean common CIMT was added. RESULTS During a median follow-up of 8.7 years, 684 first-time cardiovascular events occurred among the population with diabetes. The C statistic was 0.67 for the Framingham model and 0.68 for the CIMT model. The absolute 10 year risk for developing a myocardial infarction or stroke was 16% in both models. There was no net reclassification improvement with the addition of mean common CIMT (1.7%; 95% CI -1.8, 3.8). There were no differences in the results between men and women. CONCLUSIONS/INTERPRETATION There is no improvement in risk prediction in individuals with diabetes when measurement of the mean common CIMT is added to the Framingham risk score. Therefore, this measurement is not recommended for improving individual cardiovascular risk stratification in individuals with diabetes.
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Affiliation(s)
- H M den Ruijter
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
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van Staa TP, Smeeth L, Ng ESW, Goldacre B, Gulliford M. The efficiency of cardiovascular risk assessment: do the right patients get statin treatment? Heart 2013; 99:1597-602. [PMID: 23735939 PMCID: PMC3812879 DOI: 10.1136/heartjnl-2013-303698] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Objective To evaluate targeting of statin prescribing for primary prevention to those with high cardiovascular disease (CVD) risk. Design Two cohort studies including the general population and initiators of statins aged 35–74 years. Setting UK primary care records in the Clinical Practice Research Datalink. Patients 3.8 million general population patients and 300 914 statin users. Intervention Statin prescribing. Main outcome measures Statin prescribing by CVD risk; observed 5-year CVD risks; variability between practices. Results Statin prescribing increased substantially over time to patients with high 10-year CVD risk (≥20%): 7.0% of these received a statin prior to 2007, and 30.4% in 2007 onwards. Prescribing to patients with low risk (<15%) also increased (from 1.9% to 5.0%). Only about half the patients initiating statin treatment were high risk according to CVD risk score. The 5-year CVD risks, as observed during statin treatment, reduced over calendar time (from 17.0% to 7.1%). There was a large variation between general practices in the percentage of high-risk patients prescribed a statin in 2007 onwards, ranging from 8.2% to 61.5%. For low-risk patients, these varied from 2.1% to 29.1%. Conclusions There appeared to be substantive overuse in low CVD risk and underuse in high CVD risk (600 000 and 850 000 patients, respectively, in the UK since 2007). There is wide variation between practices in statin prescribing to patients at high CVD risk. There is a clear need for randomised trials for the best strategy to target statin treatment and manage CVD risk for primary prevention.
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Affiliation(s)
- Tjeerd-Pieter van Staa
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, , London, UK
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172
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Marshall IJ, Wang Y, McKevitt C, Rudd AG, Wolfe CDA. Trends in risk factor prevalence and management before first stroke: data from the South London Stroke Register 1995-2011. Stroke 2013; 44:1809-16. [PMID: 23660847 DOI: 10.1161/strokeaha.111.000655] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Vascular risk factors are suboptimally managed internationally. This study investigated time trends in risk factors diagnosed before stroke and their treatment, and factors associated with appropriate medication use. METHODS A total of 4416 patients with a first stroke were registered in the population-based South London Stroke Register from 1995 to 2011. Previously diagnosed risk factors and usual medications were collected from patients' primary care and hospital records. Trends and associations were assessed using multivariate logistic regression. RESULTS Seventy-two percent of patients were diagnosed previously with 1 or more risk factors; 30% had diagnosed risk factors that were untreated. Hypercholesterolemia increased significantly during the study period; myocardial infarction and transient ischemic attack prevalences decreased. Antiplatelet prescription increased in atrial fibrillation (AF), myocardial infarction, and transient ischemic attack (AF, 37%-51%, P<0.001; myocardial infarction, 48%-69%, P<0.001; transient ischemic attack, 49%-61%, P=0.015). Anticoagulant prescription for AF showed a nonsignificant increase (12%-23%; P=0.059). Fewer older patients with AF were prescribed anticoagulants (age, >85 versus <65 years; adjusted relative risk, 0.19; 95% confidence interval, 0.08-0.41). Black ethnicity (adjusted relative risk, 1.17; 95% confidence interval, 1.10-1.23) and female sex (adjusted relative risk, 1.09; 95% confidence interval, 1.03-1.15) were associated with increased antihypertensive drug prescription; other medications did not vary by ethnicity or sex. CONCLUSIONS Antiplatelet and cholesterol-lowering treatment prescribing have improved significantly over time; however, only a minority with AF received anticoagulants, and this did not improve significantly. Overall, 30% of strokes occurred in patients with previously diagnosed but untreated risk factors.
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Affiliation(s)
- Iain J Marshall
- Division of Health and Social Care Research, King's College London, London, United Kingdom
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173
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Gidlow CJ, Cochrane T, Davey R, Beloe M, Chambers R, Kumar J, Mawby Y, Iqbal Z. One-year cardiovascular risk and quality of life changes in participants of a health trainer service. Perspect Public Health 2013; 134:135-44. [PMID: 23656746 DOI: 10.1177/1757913913484419] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIMS To explore 12-month changes in cardiovascular disease (CVD) risk and health-related quality of life (HRQoL) in participants of a health trainer (HT) programme. METHODS Participants were 994 adults with at least one established CVD risk factor who were referred to a HT programme. The primary outcome was 12-month change in Framingham 10 year CVD risk score. Secondary outcomes included change in individual risk factors and HRQoL. Intention to treat analysis was used to explore 12-month changes for the overall population and those classified 'high risk' (≥20% CVD risk) at baseline. RESULTS At baseline, 33.6% of participants were classified as 'high CVD risk' and 95.7% were overweight or obese. There were modest 12-month improvements in most modifiable CVD risk factors, but not overall CVD risk (-0.25±6.50%). In 'high-risk' participants significant reductions were evident for overall CVD risk (-2.34±8.13%) and individual risk factors. Small, significant 12-month HRQoL improvements were observed, but these were not associated with CVD risk change. CONCLUSIONS Significant CVD risk reductions in participants in this HT programme with high baseline CVD risk (.20%) in HRQoL in the population as a whole indicated that the programme in its current form should target high-risk patients.
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Affiliation(s)
- Christopher J Gidlow
- Centre for Sport, Health and Exercise Research, Staffordshire University, Stoke-on-Trent, UK
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174
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Ghisi GLM, Polyzotis P, Oh P, Pakosh M, Grace SL. Physician factors affecting cardiac rehabilitation referral and patient enrollment: a systematic review. Clin Cardiol 2013; 36:323-35. [PMID: 23640785 PMCID: PMC3736151 DOI: 10.1002/clc.22126] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 03/17/2013] [Indexed: 12/28/2022] Open
Abstract
Physicians play an important role in CR referral and enrollment. Despite established benefits and recommendations, cardiac rehabilitation (CR) enrollment rates are pervasively low. The reasons cardiac patients are missing from CR programs are multifactorial and include provider factors. A number of studies have now investigated physician factors associated with referral to CR programs and patient enrollment. The objective of this study was to qualitatively and systematically review this literature. A literature search of MEDLINE, PsycINFO, CINAHL, Embase, and EBM was conducted for published articles from database inception to October 2011. Overall, 17 articles were included following a process of independent review of each article by 2 authors. Seven (41.2%) were graded as good quality according to Downs and Black criteria. There were no randomized controlled trials. Results showed that medical specialty (ie, cardiac specialists more likely to refer; n = 8 studies) and other physician-reported reasons (eg, physician report of their reasons for CR referral and physician sex) were related to referral. Physician factors related to patient enrollment in CR were physician endorsement, medical specialty, being referred, and physician attitudes toward CR. Physician factors are consistently related to CR referral and enrollment. The role of physician endorsements in promoting patient enrollment should be optimized and exploited.
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Affiliation(s)
- Gabriela L M Ghisi
- Exercise Sciences Department, Faculty of Kinesiology and Physical Education, University of Toronto, Ontario, Canada
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175
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Thrift AP, Whiteman DC. Can we really predict risk of cancer? Cancer Epidemiol 2013; 37:349-52. [PMID: 23643191 DOI: 10.1016/j.canep.2013.04.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 04/04/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Growing awareness of the potential to predict a person's future risk of cancer has resulted in the development of numerous algorithms. Such algorithms aim to improve the ability of policy makers, doctors and patients to make rational decisions about behaviour modification or surveillance, with the expectation that this activity will lead to overall benefit. There remains debate however, about whether accurate risk prediction is achievable for most cancers. METHODS We conducted a brief narrative review of the literature regarding the history and challenges of risk prediction, highlighting our own recent experiences in developing tools for oesophageal adenocarcinoma. RESULTS AND CONCLUSIONS While tools for predicting future risk of cardiovascular outcomes have been translated successfully to clinical practice, the experience with cancer risk prediction has been mixed. Models have now been developed and validated for predicting risk of melanoma and cancers of the breast, colo-rectum, lung, liver, oesophagus and prostate, and while several of these have adequate performance at the population-level, none to date have adequate discrimination for predicting risk in individual patients. Challenges of individual risk prediction for cancer are many, and include long latency, multiple risk factors of mostly small effect, and incomplete knowledge of the causal pathways.
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Affiliation(s)
- Aaron P Thrift
- Population Health Department, Queensland Institute of Medical Research, Queensland, Australia
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176
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de Gea-García JH, Benali L, Galcerá-Tomás J, Padilla-Serrano A, Andreu-Soler E, Melgarejo-Moreno A, Alonso-Fernández N. [Markers for early detection of alterations in carbohydrate metabolism after acute myocardial infarction]. Med Intensiva 2013; 38:83-91. [PMID: 23623422 DOI: 10.1016/j.medin.2013.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2012] [Revised: 01/10/2013] [Accepted: 02/03/2013] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Undiagnosed abnormal glucose metabolism is often seen in patients admitted with acute myocardial infarction, although there is no consensus on which patients should be studied with a view to establishing an early diagnosis. The present study examines the potential of certain variables obtained upon admission to diagnose abnormal glucose metabolism. DESIGN A prospective cohort study was carried out. SETTING The Intensive Care Unit of Arrixaca University Hospital (Murcia), Spain. PATIENTS A total of 138 patients admitted to the Intensive Care Unit with acute myocardial infarction and without known or de novo diabetes mellitus. After one year, oral glucose tolerance testing was performed. MAIN OUTCOMES Clinical and laboratory test parameters were recorded upon admission and one year after discharge. Additionally, after one year, oral glucose tolerance tests were made, and a study was made of the capacity of the variables obtained at admission to diagnose diabetes, based on the ROC curves and multivariate analysis. RESULTS Of the 138 patients, 112 (72.5%) had glucose metabolic alteration, including 16.7% with diabetes. HbA1c was independently associated with a diagnosis of diabetes (RR: 7.28, 95%CI 1.65 to 32.05, P = .009), and showed the largest area under the ROC curve for diabetes (0.81, 95%CI 0.69 to 0.92, P = .001). CONCLUSIONS In patients with acute myocardial infarction, HbA1c helps identify those individuals with abnormal glucose metabolism after one year. Thus, its determination in this group of patients could be used to identify those subjects requiring a more exhaustive study in order to establish an early diagnosis.
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Affiliation(s)
- J H de Gea-García
- Unidad de Cuidados Intensivos, Hospital Universitario Virgen de la Arrixaca, Murcia, España.
| | - L Benali
- Servicio de Análisis Clínicos, Hospital Universitario Virgen de la Arrixaca, Murcia, España
| | - J Galcerá-Tomás
- Unidad de Cuidados Intensivos, Hospital Universitario Virgen de la Arrixaca, Murcia, España
| | - A Padilla-Serrano
- Unidad de Cuidados Intensivos, Hospital General La Mancha Centro, Alcázar de San Juan, Ciudad Real, España
| | - E Andreu-Soler
- Unidad de Cuidados Intensivos, Hospital Universitario Virgen de la Arrixaca, Murcia, España
| | - A Melgarejo-Moreno
- Unidad de Cuidados Intensivos, Hospital Santa Lucía, Cartagena, Murcia, España
| | - N Alonso-Fernández
- Unidad de Cuidados Intensivos, Hospital Santa Lucía, Cartagena, Murcia, España
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177
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Winston A, Arenas-Pinto A, Stöhr W, Fisher M, Orkin CM, Aderogba K, De Burgh-Thomas A, O'Farrell N, Lacey CJ, Leen C, Dunn D, Paton NI. Neurocognitive function in HIV infected patients on antiretroviral therapy. PLoS One 2013; 8:e61949. [PMID: 23646111 PMCID: PMC3639991 DOI: 10.1371/journal.pone.0061949] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Accepted: 03/13/2013] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To describe factors associated with neurocognitive (NC) function in HIV-positive patients on stable combination antiretroviral therapy. DESIGN We undertook a cross-sectional analysis assessing NC data obtained at baseline in patients entering the Protease-Inhibitor-Monotherapy-Versus-Ongoing-Triple therapy (PIVOT) trial. MAIN OUTCOME MEASURE NC testing comprised of 5 domains. Raw results were z-transformed using standard and demographically adjusted normative datasets (ND). Global z-scores (NPZ-5) were derived from averaging the 5 domains and percentage of subjects with test scores >1 standard deviation (SD) below population means in at least two domains (abnormal Frascati score) calculated. Patient characteristics associated with NC results were assessed using multivariable linear regression. RESULTS Of the 587 patients in PIVOT, 557 had full NC results and were included. 77% were male, 68% Caucasian and 28% of Black ethnicity. Mean (SD) baseline and nadir CD4+ lymphocyte counts were 553(217) and 177(117) cells/µL, respectively, and HIV RNA was <50 copies/mL in all. Median (IQR) NPZ-5 score was -0.5 (-1.2/-0) overall, and -0.3 (-0.7/0.1) and -1.4 (-2/-0.8) in subjects of Caucasian and Black ethnicity, respectively. Abnormal Frascati scores using the standard-ND were observed in 51%, 38%, and 81%, respectively, of subjects overall, Caucasian and Black ethnicity (p<0.001), but in 62% and 69% of Caucasian and Black subjects using demographically adjusted-ND (p = 0.20). In the multivariate analysis, only Black ethnicity was associated with poorer NPZ-5 scores (P<0.001). CONCLUSIONS In this large group of HIV-infected subjects with viral load suppression, ethnicity but not HIV-disease factors is closely associated with NC results. The prevalence of abnormal results is highly dependent on control datasets utilised. TRIAL REGISTRY ClinicalTrials.gov, NCT01230580.
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Affiliation(s)
- Alan Winston
- Section of Infectious Diseases, Division of Medicine, Imperial College London, St Mary's Hospital Campus, Norfolk Place, London, United Kingdom.
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O'Brien C, Bray EP, Bryan S, Greenfield SM, Haque MS, Hobbs FDR, Jones MI, Jowett S, Kaambwa B, Little P, Mant J, Penaloza C, Schwartz C, Shackleford H, Varghese J, Williams B, McManus RJ. Targets and self-management for the control of blood pressure in stroke and at risk groups (TASMIN-SR): protocol for a randomised controlled trial. BMC Cardiovasc Disord 2013; 13:21. [PMID: 23522245 PMCID: PMC3623796 DOI: 10.1186/1471-2261-13-21] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Accepted: 03/13/2013] [Indexed: 11/10/2022] Open
Abstract
Background Self-monitoring of hypertension with self-titration of antihypertensives (self-management) results in lower systolic blood pressure for at least one year. However, few people in high risk groups have been evaluated to date and previous work suggests a smaller effect size in these groups. This trial therefore aims to assess the added value of self-management in high risk groups over and above usual care. Methods/Design The targets and self-management for the control of blood pressure in stroke and at risk groups (TASMIN-SR) trial will be a pragmatic primary care based, unblinded, randomised controlled trial of self-management of blood pressure (BP) compared to usual care. Eligible patients will have a history of stroke, coronary heart disease, diabetes or chronic kidney disease and will be recruited from primary care. Participants will be individually randomised to either usual care or self-management. The primary outcome of the trial will be difference in office SBP between intervention and control groups at 12 months adjusted for baseline SBP and covariates. 540 patients will be sufficient to detect a difference in SBP between self-management and usual care of 5 mmHg with 90% power. Secondary outcomes will include self-efficacy, lifestyle behaviours, health-related quality of life and adverse events. An economic analysis will consider both within trial costs and a model extrapolating the results thereafter. A qualitative analysis will gain insights into patients’ views, experiences and decision making processes. Discussion The results of the trial will be directly applicable to primary care in the UK. If successful, self-management of blood pressure in people with stroke and other high risk conditions would be applicable to many hundreds of thousands of individuals in the UK and beyond. Trial Registration ISRCTN87171227
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Affiliation(s)
- Claire O'Brien
- Primary Care Clinical Sciences, NIHR School for Primary Care Research, University of Birmingham, Edgbaston, Birmingham, UK
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Hunt BD, Hiles SL, Chauhan A, Ighofose C, Bharakhada N, Jain A, Davies MJ, Khunti K. Evaluation of the Healthy LifeCheck programme: a vascular risk assessment service for community pharmacies in Leicester city, UK. J Public Health (Oxf) 2013; 35:440-6. [PMID: 23479477 DOI: 10.1093/pubmed/fdt017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) is the leading cause of death globally. Vascular risk assessment is recognized as playing a key role in reducing premature CVD-related morbidity and mortality. The current study evaluated the effectiveness of a pharmacy-led risk assessment service in Leicester City, UK. METHODS The vascular risk assessment was offered opportunistically to individuals between 40 and 70 years without any prior diagnosis of CVD on attending their community pharmacist. Individuals were risk stratified using the Framingham score and those classified as high risk were referred to their general practitioner (GP). RESULTS Overall, 2521 individuals were recruited from 39 pharmacies consisting of 1059 (42%) males, 1696 (67%) South Asians and 199 (7.9%) individuals not registered with a GP. A total of 462 (18%) individuals were referred to primary care and 52.6% of a representative subset were subsequently recorded as having attended an appointment with their GP; diagnoses and treatments commenced were recorded. CONCLUSIONS Cardiovascular risk assessment led by community pharmacies can successfully assess people from large, multi-ethnic UK populations and identify those at high cardiovascular risk or with undiagnosed cardiovascular disease. The service may improve rates of assessments undertaken by individuals who do not access health care through traditional routes.
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Affiliation(s)
- Benjamin D Hunt
- Leicester Diabetes Centre, Leicester General Hospital, Gwendolyn Road, Leicester, UK.
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Cochrane T, Gidlow CJ, Kumar J, Mawby Y, Iqbal Z, Chambers RM. Cross-sectional review of the response and treatment uptake from the NHS Health Checks programme in Stoke on Trent. J Public Health (Oxf) 2013; 35:92-8. [PMID: 23104892 PMCID: PMC3580053 DOI: 10.1093/pubmed/fds088] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Revised: 09/14/2012] [Accepted: 09/28/2012] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND As part of national policy to manage the increasing burden of chronic diseases, the Department of Health in England has launched the NHS Health Checks programme, which aims to reduce the burden of the major vascular diseases on the health service. METHODS A cross-sectional review of response, attendance and treatment uptake over the first year of the programme in Stoke on Trent was carried out. Patients aged between 32 and 74 years and estimated to be at ≥20% risk of developing cardiovascular disease were identified from electronic medical records. Multi-level regression modelling was used to evaluate the influence of individual- and practice-level factors on health check outcomes. RESULTS Overall 63.3% of patients responded, 43.7% attended and 29.8% took up a treatment following their health check invitation. The response was higher for older age and more affluent areas; attendance and treatment uptake were higher for males and older age. Variance between practices was significant (P < 0.001) for response (13.4%), attendance (12.7%) and uptake (23%). CONCLUSIONS The attendance rate of 43.7% following invitation to a health check was considerably lower than the benchmark of 75%. The lack of public interest and the prevalence of significant comorbidity are challenges to this national policy innovation.
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Affiliation(s)
- Thomas Cochrane
- Centre for Research and Action in Public Health, Faculty of Health, University of Canberra, ACT 2601, Australia.
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Jones CA, Nanji A, Mawani S, Davachi S, Ross L, Vollman A, Aggarwal S, King-Shier K, Campbell N. Feasibility of community-based screening for cardiovascular disease risk in an ethnic community: the South Asian Cardiovascular Health Assessment and Management Program (SA-CHAMP). BMC Public Health 2013; 13:160. [PMID: 23432996 PMCID: PMC3614427 DOI: 10.1186/1471-2458-13-160] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Accepted: 02/19/2013] [Indexed: 01/05/2023] Open
Abstract
Background South Asian Canadians experience disproportionately high rates of cardiovascular disease (CVD). The goal of this qualitative study was to determine the feasibility of implementing a sustainable, culturally adapted, community-based CVD risk factor screening program for this population. Methods South Asians (≥ 45 years) in Calgary, Alberta underwent opportunistic cardiovascular risk factor screening by lay trained volunteers at local religious facilities. Those with elevated blood pressure (BP) or ≥ 1 risk factor underwent point of care cholesterol testing, 10-year CVD risk calculation, counseling, and referral to family physicians and local culturally tailored chronic disease management (CDM) programs. Participants were invited for re-screening and were surveyed about health system follow-up, satisfaction with the program and suggestions for improvement. Changes in risk factors from baseline were estimated using McNemar’s test (proportions) and paired t-tests (continuous measures). Results Baseline assessment was completed for 238 participants (median age 64 years, 51% female). Mean TC, HDL and TC/HDL were 5.41 mmol/L, 1.12 mmol/L and 4.7, respectively. Mean systolic and diastolic blood pressures (mmHg) were 129 and 75 respectively. Blood pressure and TC/HDL ratios exceeded recommended targets in 36% and 58%, respectively, and 76% were at high risk for CVD. Ninety-nine participants (47% female) attended re-screening. 82% had accessed health care providers, 22% reported medication changes and 3.5% had attended the CDM programs. While BP remained unchanged, TC and TC/HDL decreased and HDL increased significantly (mean differences: -0.52 mmol/L, -1.04 and +0.07 mmol/L, respectively). Participants were very satisfied (80%) or satisfied (20%) with the project. Participants suggested screening sessions and CDM programs be more accessible by: delivering evening or weekends programs at more sites, providing transportation, offering multilingual programs/translation assistance, reducing screening wait times and increasing numbers of project staff. Conclusions SA-CHAMP demonstrated the feasibility and value of implementing a lay volunteer–led, culturally adapted, sustainable community-based CVD risk factor screening program in South Asian places of worship in Calgary, Alberta, Canada. Subsequent screening and CDM programs were refined based on the learnings from this study. Further research is needed to determine physician and patient factors associated with uptake of and adherence to risk reduction strategies.
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Affiliation(s)
- Charlotte A Jones
- Department of Medicine, University of Calgary, Libin Cardiovascular Institute, TRW Building GE89, 3280 Hospital Drive NW, Calgary, AB, Canada.
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Karmali KN, Lloyd-Jones DM. Adding a life-course perspective to cardiovascular-risk communication. Nat Rev Cardiol 2013; 10:111-5. [DOI: 10.1038/nrcardio.2012.185] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Chapter 4: Other complications of CKD: CVD, medication dosage, patient safety, infections, hospitalizations, and caveats for investigating complications of CKD. Kidney Int Suppl (2011) 2013; 3:91-111. [PMID: 25599000 PMCID: PMC4284425 DOI: 10.1038/kisup.2012.67] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Sud R, Roy B, Emerson J, Hennessy A. Associations between family history of cardiovascular disease, knowledge of cardiovascular disease risk factors and health behaviours. Aust J Prim Health 2013; 19:119-23. [DOI: 10.1071/py12010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2011] [Accepted: 02/21/2012] [Indexed: 11/23/2022]
Abstract
The objective of the study was to examine associations between family history of premature cardiovascular disease (CVD), knowledge of CVD risk and protective factors, and health behaviours. The design was via administration of a questionnaire to 307 participants from four general practice centre waiting rooms in the Sydney West area. The most recognised CVD risk factor was smoking (97.7%) and the most recognised CVD protective factor was omega-3 fatty acids (78.5%). After adjustment for age, sex, education attainment and personal history of CVD, a strong family history of premature CVD was associated with being more likely to interpret a blood pressure of 130/85 as a CVD risk factor (OR 2.77, 95% CI 1.07–7.14), but less likely to identify being an ex-smoker (compared with never having smoked before) as a risk factor (OR 0.32, 95% CI 0.12–0.90). Those with a strong family history of premature CVD, on average, had smoked 0.82 pack years more than those with an average family history of premature CVD (s.e. 4.22, P = 0.04). In conclusion, there continues to be both strengths and deficits in the community’s overall knowledge of CVD risk and protective factors, and a strong family history of premature CVD appears to be an independent risk factor for smoking.
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Elwood PC, Almonte M, Mustafa M. Is There Enough Evidence for Aspirin in High-Risk Groups? CURRENT COLORECTAL CANCER REPORTS 2012. [DOI: 10.1007/s11888-012-0149-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Kim BJ, Lee SH, Ryu WS, Kim CK, Chung JW, Kim D, Park HK, Bae HJ, Park BJ, Yoon BW. Excessive work and risk of haemorrhagic stroke: a nationwide case-control study. Int J Stroke 2012; 8 Suppl A100:56-61. [PMID: 23227896 DOI: 10.1111/j.1747-4949.2012.00949.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Adverse effect of excessive work on health has been suggested previously, but it was not documented in cerebrovascular diseases. AIM The authors investigated whether excessive working conditions would associate with increased risk of haemorrhagic stroke. METHODS A nationwide matched case-control study database, which contains 940 cases of incident haemorrhagic stroke (498 intracerebral haemorrhages and 442 sub-arachnoid haemorrhages) with 1880 gender- and age- (± 5-year) matched controls, was analysed. Work-related information based on the regular job situation, including type of occupation, regular working time, duration of strenuous activity during regular work and shift work, was gathered through face-to-face interviews. Conditional logistic regression analyses were used for the multivariable analyses. RESULTS Compared with white-collar workers, blue-collar workers had a higher risk for haemorrhagic stroke (odds ratio, 1.33 [95% confidence interval, 1.06-1.66]). Longer regular working time was associated with increased risk of haemorrhagic stroke [odds ratio, 1.38 (95% confidence interval, 1.05-1.81) for 8-12 h/day; odds ratio, 1.95 (95% confidence interval, 1.33-2.86) for ≥ 13 h/day; compared with ≤ 4 h/day]. Exposure to ≥ 8 h/week of strenuous activity also associated haemorrhagic stroke risk [odds ratio, 1.61 (95% confidence interval, 1.26-2.05); compared with no strenuous activity]. Shift work was not associated with haemorrhagic stroke (P = 0.98). Positive associations between working condition indices and haemorrhagic stroke risk were consistent regardless of haemorrhagic stroke sub-types and current employment status. CONCLUSIONS Blue-collar occupation, longer regular working time and extended duration of strenuous activity during work may relate to an increased risk of haemorrhagic stroke.
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Affiliation(s)
- Beom Joon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam-si, Gyunggi-do, Republic of Korea; Department of Neurology, Clinical Research Centre for Stroke, Seoul National University Hospital, Seoul, Republic of Korea
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Scarisbrick JJ, Morris S, Azurdia R, Illidge T, Parry E, Graham-Brown R, Cowan R, Gallop-Evans E, Wachsmuth R, Eagle M, Wierzbicki AS, Soran H, Whittaker S, Wain EM. U.K. consensus statement on safe clinical prescribing of bexarotene for patients with cutaneous T-cell lymphoma. Br J Dermatol 2012; 168:192-200. [PMID: 22963233 DOI: 10.1111/bjd.12042] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Bexarotene is a synthetic retinoid from the subclass of retinoids called rexinoids which selectively activate retinoid X receptors. It has activity in cutaneous T-cell lymphoma (CTCL) and has been approved by the European Medicines Agency since 1999 for treatment of the skin manifestations of advanced-stage (IIB-IVB) CTCL in adult patients refractory to at least one systemic treatment. In vivo bexarotene produces primary hypothyroidism which may be managed with thyroxine replacement. It also affects lipid metabolism, typically resulting in raised triglycerides, which requires prophylactic lipid-modification therapy. Effects on neutrophils, glucose and liver function may also occur. These side-effects are dose dependent and may be controlled with corrective therapy or dose adjustments. OBJECTIVES To produce a U.K. statement outlining a bexarotene dosing schedule and monitoring protocol to enable bexarotene prescribers to deliver bexarotene safely for optimal effect. METHODS Leaders from U.K. supraregional centres produced this consensus statement after a series of meetings and a review of the literature. RESULTS The statement outlines a bexarotene dosing schedule and monitoring protocol. This gives instructions on monitoring and treating thyroid, lipid, liver, blood count, creatine kinase, glucose and amylase abnormalities. The statement also includes algorithms for a bexarotene protocol and lipid management, which may be used in the clinical setting. CONCLUSION Clinical prescribing of bexarotene for patients with CTCL requires careful monitoring to allow safe administration of bexarotene at the optimal dose.
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Chapter 4: Blood pressure management in CKD ND patients with diabetes mellitus. Kidney Int Suppl (2011) 2012; 2:363-369. [PMID: 25018963 PMCID: PMC4089765 DOI: 10.1038/kisup.2012.54] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Waters L, Patterson B, Scourfield A, Hughes A, de Silva S, Gazzard B, Barton S, Asboe D, Pozniak A, Boffito M. A dedicated clinic for HIV-positive individuals over 50 years of age: a multidisciplinary experience. Int J STD AIDS 2012; 23:546-52. [PMID: 22930290 DOI: 10.1258/ijsa.2012.011412] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The HIV-infected population is ageing. Issues including polypharmacy and co-morbidities led us to develop a dedicated clinic for HIV-infected individuals over 50. We describe our service evaluation after two years. The over 50 clinic commenced in January 2009. The team comprises a registrar, consultant, nurse practitioner and is supported by a pharmacist and mental health services. Patients undergo a full medication and drug interactions review, neurocognitive assessment, adherence self-assessment and investigations including therapeutic drug monitoring (TDM), coronary artery calcium scores (CACS) and bone mineral density. Over two years of activity, 150 patients attended the service. Median (range) age was 58 (50-88), all were on combined antiretroviral therapy and 38% (57/150) were on ≥3 non-HIV drugs. CACS was high (>90th centile) in 14%. Thirty-eight percent had osteopaenia and 18% had osteoporosis requiring treatment. Thirteen out of 125 men had an increased prostate specific antigen, four were diagnosed with prostate cancer. Drug interaction, TDM and neurocognitive assessments were useful for several patients. Asymptomatic patients over 50 in long-term follow-up had new pathologies detected through targeted screening. The clinic has improved general practitioner (GP) liaison and facilitated closer working relationships with other specialties. Patients have reacted positively to the clinic, particularly as many do not routinely access their GP.
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Affiliation(s)
- L Waters
- Department of GU/HIV Medicine, Chelsea & Westminster Hospital, London, UK.
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Khan R, Foster GR, Chowdhury TA. Managing diabetes in patients with chronic liver disease. Postgrad Med 2012; 124:130-7. [PMID: 22913901 DOI: 10.3810/pgm.2012.07.2574] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Diabetes and chronic liver disease (CLD) are common long-term conditions in the developed and developing world. The 2 conditions often coexist, and there is evidence to suggest that diabetes can have a significant adverse effect on patients with CLD, leading to increased complications and premature mortality. While diabetes, nonalcoholic fatty liver disease, and nonalcoholic steatohepatitis (NASH) appear to have common origins related to obesity and insulin resistance, diabetes is also common among patients with alcoholic and viral CLD. In patients with NASH, improvement in metabolic indices appears to reduce the progression of CLD. It is not clear whether improving glycemic control in other forms of CLD leads to improved outcomes. Managing diabetes in patients with CLD can be challenging because many antihyperglycemic therapies are contraindicated or must be used with care. Metformin and pioglitazone may be useful in patients with NASH, but sulfonylureas and insulin must be used with caution, as hypoglycemia may be a problem. Insulin doses frequently need to be reduced in patients with CLD. Newer glycemic agents have not been widely used in patients with CLD, but bariatric surgery may lead to significant improvement in liver indices in patients with NASH. Management of patients with diabetes and CLD may be enhanced by using a multidisciplinary approach.
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Affiliation(s)
- Roaid Khan
- Department of Diabetes and Metabolism, The Royal London Hospital, London, UK
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Cochrane T, Davey R, Iqbal Z, Gidlow C, Kumar J, Chambers R, Mawby Y. NHS health checks through general practice: randomised trial of population cardiovascular risk reduction. BMC Public Health 2012; 12:944. [PMID: 23116213 PMCID: PMC3524756 DOI: 10.1186/1471-2458-12-944] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Accepted: 10/15/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The global burden of the major vascular diseases is projected to rise and to remain the dominant non-communicable disease cluster well into the twenty first century. The Department of Health in England has developed the NHS Health Check service as a policy initiative to reduce population vascular disease risk. The aims of this study were to monitor population changes in cardiovascular disease (CVD) risk factors over the first year of the new service and to assess the value of tailored lifestyle support, including motivational interview with ongoing support and referral to other services. METHODS Randomised trial comparing NHS Health Check service only with NHS Health Check service plus additional lifestyle support in Stoke on Trent, England. Thirty eight general practices and 601 (365 usual care, 236 additional lifestyle support) patients were recruited and randomised independently between September 2009 and February 2010. Changes in population CVD risk between baseline and one year follow-up were compared, using intention-to-treat analysis. The primary outcome was the Framingham 10 year CVD risk score. Secondary outcomes included individual modifiable risk measures and prevalence of individual risk categories. Additional lifestyle support included referral to a lifestyle coach and free sessions as needed for: weight management, physical activity, cook and eat and positive thinking. RESULTS Average population CVD risk decreased from 32.9% to 29.4% (p <0.001) in the NHS Health Check only group and from 31.9% to 29.2% (p <0.001) in the NHS Health Check plus additional lifestyle support group. There was no significant difference between the two groups at either measurement point. Prevalence of high blood pressure, high cholesterol and smoking were reduced significantly (p <0.01) in both groups. Prevalence of central obesity was reduced significantly (p <0.01) in the group receiving additional lifestyle support but not in the NHS Health Check only group. CONCLUSIONS The NHS Health Check service in Stoke on Trent resulted in significant reduction in estimated population CVD risk. There was no evidence of further benefit of the additional lifestyle support services in terms of absolute CVD risk reduction.
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Affiliation(s)
- Thomas Cochrane
- Centre for Research and Action in Public Health, Faculty of Health, University of Canberra, Canberra ACT2601, Australia
| | - Rachel Davey
- Centre for Research and Action in Public Health, Faculty of Health, University of Canberra, Canberra ACT2601, Australia
| | - Zafar Iqbal
- NHS Stoke on Trent, Directorate Public Health, Civic Centre, Glebe Street, Stoke on Trent, ST4 1HH, United Kingdom
| | - Christopher Gidlow
- Centre for Sport, Health and Exercise Research, Staffordshire University, Leek Road Campus, Stoke on Trent, ST4 2DF, United Kingdom
| | - Jagdish Kumar
- NHS Stoke on Trent, Directorate Public Health, Civic Centre, Glebe Street, Stoke on Trent, ST4 1HH, United Kingdom
| | - Ruth Chambers
- NHS Stoke on Trent, Directorate Public Health, Civic Centre, Glebe Street, Stoke on Trent, ST4 1HH, United Kingdom
| | - Yvonne Mawby
- NHS Stoke on Trent, Directorate Public Health, Civic Centre, Glebe Street, Stoke on Trent, ST4 1HH, United Kingdom
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Marshall T, Caley M, Hemming K, Gill P, Gale N, Jolly K. Mixed methods evaluation of targeted case finding for cardiovascular disease prevention using a stepped wedged cluster RCT. BMC Public Health 2012; 12:908. [PMID: 23101763 PMCID: PMC3505746 DOI: 10.1186/1471-2458-12-908] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 10/24/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A pilot project cardiovascular prevention was implemented in Sandwell (West Midlands, UK). This used electronic primary care records to identify untreated patients at high risk of cardiovascular disease then invited these high risk patients for assessment by a nurse in their own general practice. Those found to be eligible for treatment were offered treatment. During the pilot a higher proportion of high risk patients were started on treatment in the intervention practices than in control practices. Following the apparent success of the prevention project, it was intended to extend the service to all practices across the Sandwell area. However the pilot project was not a robust evaluation. There was a need for an efficient evaluation that would not disrupt the planned rollout of the project. METHODS/DESIGN Project nurses will sequentially implement targeted cardiovascular case finding in a phased way across all general practices, with the sequence of general practices determined randomly. This is a stepped wedge randomised controlled trial design. The target population is patients aged 35 to 74, without diabetes or cardiovascular disease whose ten-year cardiovascular risk, (determined from data in their electronic records) is ≥ 20%. The primary outcome is the number of high risk patients started on treatment, because these data could be efficiently obtained from electronic primary care records. From this we can determine the effects of the case finding programme on the proportion of high risk patients started on treatment in practices before and after implementation of targeted case finding. Cost-effectiveness will be modelled from the predicted effects of treatments on cardiovascular events and associated health service costs. Alongside the implementation it is intended to interview clinical staff and patients who participated in the programme in order to determine acceptability to patients and clinicians. Practical considerations meant that 26 practices in Sandwell could be randomised, including about 6,250 patients at high risk of cardiovascular disease. This gives sufficient power for evaluation. DISCUSSION It is possible to design a stepped wedge randomised controlled trial using routine data to determine the primary outcome to evaluate implementation of a cardiovascular prevention programme.
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Affiliation(s)
- Tom Marshall
- School of Health and Population Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Michael Caley
- Warwickshire Primary Care Trust, Westgate House, Market Street, Warwick, CV34 4DE, UK
| | - Karla Hemming
- School of Health and Population Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Paramjit Gill
- School of Health and Population Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Nicola Gale
- School of Health and Population Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Kate Jolly
- School of Health and Population Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
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Schutte R, Thijs L, Liu YP, Asayama K, Jin Y, Odili A, Gu YM, Kuznetsova T, Jacobs L, Staessen JA. Within-subject blood pressure level--not variability--predicts fatal and nonfatal outcomes in a general population. Hypertension 2012; 60:1138-47. [PMID: 23071126 DOI: 10.1161/hypertensionaha.112.202143] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
To assess the prognostic significance of blood pressure (BP) variability, we followed health outcomes in a family-based random population sample representative of the general population (n=2944; mean age: 44.9 years; 50.7% women). At baseline, BP was measured 5 times consecutively at each of 2 home visits 2 to 4 weeks apart. We assessed within-subject overall (10 readings), within- and between-visit systolic BP variability from variability independent of the mean, the difference between maximum and minimum BP, and average real variability. Over a median follow-up of 12 years, 401 deaths occurred and 311 participants experienced a fatal or nonfatal cardiovascular event. Overall systolic BP variability averaged (SD) 5.45 (2.82) units, 15.87 (8.36) mmHg, and 4.08 (2.05) mmHg for variability independent of the mean, difference between maximum and minimum BP, and average real variability, respectively. Female sex, older age, higher-mean systolic BP, lower body mass index, a history of peripheral arterial disease, and use of β-blockers were the main correlates of systolic BP variability. In multivariable-adjusted analyses, overall and within- and between-visit BP variability did not predict total or cardiovascular mortality or the composite of any fatal plus nonfatal cardiovascular end point. For instance, the hazard ratios for all cardiovascular events combined in relation to overall variability independent of the mean, difference between maximum and minimum BP, and average real variability were 1.05 (0.96-1.15), 1.06 (0.96-1.16), and 1.08 (0.98-1.19), respectively. By contrast, mean systolic BP was a significant predictor of all end points under study, independent of BP variability. In conclusion, in an unbiased population sample, BP variability did not contribute to risk stratification over and beyond mean systolic BP.
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Affiliation(s)
- Rudolph Schutte
- Department of Cardiovascular Sciences, Studies Coordinating Centre, Division of Hypertension and Cardiovascular Rehabilitation, University of Leuven, Campus Sint Rafaël, Kapucijnenvoer 35, Block D, Box 7001, BE-3000 Leuven, Belgium
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Abstract
Reducing elevated LDL-cholesterol is a key public health challenge. There is substantial evidence from randomised controlled trials (RCT) that a number of foods and food components can significantly reduce LDL-cholesterol. Data from RCT have been reviewed to determine whether effects are additive when two or more of these components are consumed together. Typically components, such as plant stanols and sterols, soya protein, β-glucans and tree nuts, when consumed individually at their target rate, reduce LDL-cholesterol by 3-9 %. Improved dietary fat quality, achieved by replacing SFA with unsaturated fat, reduces LDL-cholesterol and can increase HDL-cholesterol, further improving blood lipid profile. It appears that the effect of combining these interventions is largely additive; however, compliance with multiple changes may reduce over time. Food combinations used in ten 'portfolio diet' studies have been reviewed. In clinical efficacy studies of about 1 month where all foods were provided, LDL-cholesterol is reduced by 22-30 %, whereas in community-based studies of >6 months' duration, where dietary advice is the basis of the intervention, reduction in LDL-cholesterol is about 15 %. Inclusion of MUFA into 'portfolio diets' increases HDL-cholesterol, in addition to LDL-cholesterol effects. Compliance with some of these dietary changes can be achieved more easily compared with others. By careful food component selection, appropriate to the individual, the effect of including only two components in the diet with good compliance could be a sustainable 10 % reduction in LDL-cholesterol; this is sufficient to make a substantial impact on cholesterol management and reduce the need for pharmaceutical intervention.
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198
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Affiliation(s)
- Emma C Wylie
- Richard Bright Renal Unit, Southmead Hospital and Academic Renal Unit, University of Bristol
| | - Simon C Satchell
- Richard Bright Renal Unit, Southmead Hospital and Academic Renal Unit, University of Bristol
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199
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Hussain ST, Paul M, Plein S, McCann GP, Shah AM, Marber MS, Chiribiri A, Morton G, Redwood S, MacCarthy P, Schuster A, Ishida M, Westwood MA, Perera D, Nagel E. Design and rationale of the MR-INFORM study: stress perfusion cardiovascular magnetic resonance imaging to guide the management of patients with stable coronary artery disease. J Cardiovasc Magn Reson 2012; 14:65. [PMID: 22992411 PMCID: PMC3533866 DOI: 10.1186/1532-429x-14-65] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Accepted: 08/09/2012] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND In patients with stable coronary artery disease (CAD), decisions regarding revascularisation are primarily driven by the severity and extent of coronary luminal stenoses as determined by invasive coronary angiography. More recently, revascularisation decisions based on invasive fractional flow reserve (FFR) have shown improved event free survival. Cardiovascular magnetic resonance (CMR) perfusion imaging has been shown to be non-inferior to nuclear perfusion imaging in a multi-centre setting and superior in a single centre trial. In addition, it is similar to invasively determined FFR and therefore has the potential to become the non-invasive test of choice to determine need for revascularisation. TRIAL DESIGN The MR-INFORM study is a prospective, multi-centre, randomised controlled non-inferiority, outcome trial. The objective is to compare the efficacy of two investigative strategies for the management of patients with suspected CAD. Patients presenting with stable angina are randomised into two groups: 1) The FFR-INFORMED group has subsequent management decisions guided by coronary angiography and fractional flow reserve measurements. 2) The MR-INFORMED group has decisions guided by stress perfusion CMR. The primary end-point will be the occurrence of major adverse cardiac events (death, myocardial infarction and repeat revascularisation) at one year. Clinical trials.gov identifier NCT01236807. CONCLUSION MR INFORM will assess whether an initial strategy of CMR perfusion is non-inferior to invasive angiography supplemented by FFR measurements to guide the management of patients with stable coronary artery disease. Non-inferiority of CMR perfusion imaging to the current invasive reference standard (FFR) would establish CMR perfusion imaging as an attractive non-invasive alternative to current diagnostic pathways.
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Affiliation(s)
- Shazia T Hussain
- King’s College London, British Heart Foundation (BHF) Centre of Research Excellence, National Institute for Health Research (NIHR) Biomedical Research Centre at Guy’s and St. Thomas’ NHS Trust Foundation, Joint Imaging and Cardiovascular Divisions, Kings Health Partners, 4th Floor Lambeth Wing, St. Thomas' Hospital, London, SE1 7EH, UK
| | - Matthias Paul
- King’s College London, British Heart Foundation (BHF) Centre of Research Excellence, National Institute for Health Research (NIHR) Biomedical Research Centre at Guy’s and St. Thomas’ NHS Trust Foundation, Joint Imaging and Cardiovascular Divisions, Kings Health Partners, 4th Floor Lambeth Wing, St. Thomas' Hospital, London, SE1 7EH, UK
| | - Sven Plein
- Multidisciplinary Cardiovascular Research Centre & Leeds Institute of Genetics, Health and Therapeutics, University of Leeds, Leeds, United Kingdom
| | - Gerry P McCann
- NIHR Leicester Cardiovascular Biomedical Research Unit, Leicester, UK
| | - Ajay M Shah
- King’s College London, British Heart Foundation (BHF) Centre of Research Excellence, National Institute for Health Research (NIHR) Biomedical Research Centre at Guy’s and St. Thomas’ NHS Trust Foundation, Joint Imaging and Cardiovascular Divisions, Kings Health Partners, 4th Floor Lambeth Wing, St. Thomas' Hospital, London, SE1 7EH, UK
| | - Michael S Marber
- King’s College London, British Heart Foundation (BHF) Centre of Research Excellence, National Institute for Health Research (NIHR) Biomedical Research Centre at Guy’s and St. Thomas’ NHS Trust Foundation, Joint Imaging and Cardiovascular Divisions, Kings Health Partners, 4th Floor Lambeth Wing, St. Thomas' Hospital, London, SE1 7EH, UK
| | - Amedeo Chiribiri
- King’s College London, British Heart Foundation (BHF) Centre of Research Excellence, National Institute for Health Research (NIHR) Biomedical Research Centre at Guy’s and St. Thomas’ NHS Trust Foundation, Joint Imaging and Cardiovascular Divisions, Kings Health Partners, 4th Floor Lambeth Wing, St. Thomas' Hospital, London, SE1 7EH, UK
| | - Geraint Morton
- King’s College London, British Heart Foundation (BHF) Centre of Research Excellence, National Institute for Health Research (NIHR) Biomedical Research Centre at Guy’s and St. Thomas’ NHS Trust Foundation, Joint Imaging and Cardiovascular Divisions, Kings Health Partners, 4th Floor Lambeth Wing, St. Thomas' Hospital, London, SE1 7EH, UK
| | - Simon Redwood
- King’s College London, British Heart Foundation (BHF) Centre of Research Excellence, National Institute for Health Research (NIHR) Biomedical Research Centre at Guy’s and St. Thomas’ NHS Trust Foundation, Joint Imaging and Cardiovascular Divisions, Kings Health Partners, 4th Floor Lambeth Wing, St. Thomas' Hospital, London, SE1 7EH, UK
| | - Philip MacCarthy
- King’s College London, British Heart Foundation (BHF) Centre of Research Excellence, National Institute for Health Research (NIHR) Biomedical Research Centre at Guy’s and St. Thomas’ NHS Trust Foundation, Joint Imaging and Cardiovascular Divisions, Kings Health Partners, 4th Floor Lambeth Wing, St. Thomas' Hospital, London, SE1 7EH, UK
| | - Andreas Schuster
- King’s College London, British Heart Foundation (BHF) Centre of Research Excellence, National Institute for Health Research (NIHR) Biomedical Research Centre at Guy’s and St. Thomas’ NHS Trust Foundation, Joint Imaging and Cardiovascular Divisions, Kings Health Partners, 4th Floor Lambeth Wing, St. Thomas' Hospital, London, SE1 7EH, UK
- Department of Cardiology and Pneumology and Heart Research Center, Georg-August-University, Göttingen, Germany
| | - Masaki Ishida
- King’s College London, British Heart Foundation (BHF) Centre of Research Excellence, National Institute for Health Research (NIHR) Biomedical Research Centre at Guy’s and St. Thomas’ NHS Trust Foundation, Joint Imaging and Cardiovascular Divisions, Kings Health Partners, 4th Floor Lambeth Wing, St. Thomas' Hospital, London, SE1 7EH, UK
| | | | - Divaka Perera
- King’s College London, British Heart Foundation (BHF) Centre of Research Excellence, National Institute for Health Research (NIHR) Biomedical Research Centre at Guy’s and St. Thomas’ NHS Trust Foundation, Joint Imaging and Cardiovascular Divisions, Kings Health Partners, 4th Floor Lambeth Wing, St. Thomas' Hospital, London, SE1 7EH, UK
| | - Eike Nagel
- King’s College London, British Heart Foundation (BHF) Centre of Research Excellence, National Institute for Health Research (NIHR) Biomedical Research Centre at Guy’s and St. Thomas’ NHS Trust Foundation, Joint Imaging and Cardiovascular Divisions, Kings Health Partners, 4th Floor Lambeth Wing, St. Thomas' Hospital, London, SE1 7EH, UK
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200
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Abstract
Cardiovascular disease is a major, growing, worldwide problem. It is important that individuals at risk of developing cardiovascular disease can be effectively identified and appropriately stratified according to risk. This review examines what we understand by the term risk, traditional and novel risk factors, clinical scoring systems, and the use of risk for informing prescribing decisions. Many different cardiovascular risk factors have been identified. Established, traditional factors such as ageing are powerful predictors of adverse outcome, and in the case of hypertension and dyslipidaemia are the major targets for therapeutic intervention. Numerous novel biomarkers have also been described, such as inflammatory and genetic markers. These have yet to be shown to be of value in improving risk prediction, but may represent potential therapeutic targets and facilitate more targeted use of existing therapies. Risk factors have been incorporated into several cardiovascular disease prediction algorithms, such as the Framingham equation, SCORE and QRISK. These have relatively poor predictive power, and uncertainties remain with regards to aspects such as choice of equation, different risk thresholds and the roles of relative risk, lifetime risk and reversible factors in identifying and treating at-risk individuals. Nonetheless, such scores provide objective and transparent means of quantifying risk and their integration into therapeutic guidelines enables equitable and cost-effective distribution of health service resources and improves the consistency and quality of clinical decision making.
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Affiliation(s)
- Rupert A Payne
- General Practice and Primary Care Research Unit, University of Cambridge, UK.
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