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

The comparative efficacy of ezetimibe added to atorvastatin 10 mg versus uptitration to atorvastatin 40 mg in subgroups of patients aged 65 to 74 years or greater than or equal to 75 years

Background

Coronary heart disease (CHD) risk increases with age; yet lipid-lowering therapies are significantly under-utilized in patients > 65 years. The objective was to evaluate the safety and efficacy of lipid-lowering therapies in older patients treated with atorvastatin 10 mg + ezetimibe 10 mg (EZ/Atorva) vs. increasing the atorvastatin dose to 40 mg.

Methods

Patients ≥ 65 years with atherosclerotic vascular disease (LDL-C ≥ 1.81 mmol/L) or at high risk for coronary heart disease (LDL-C ≥ 2.59 mmol/L) were randomized to EZ/Atorva for 12 wk vs. uptitration to atorvastatin 20 mg for 6 wk followed by atorvastatin 40 mg for 6 wk. The percent change in LDL-C and other lipid parameters and percent patients achieving prespecified LDL-C levels were assessed after 12 wk.

Results

EZ/Atorva produced greater reductions in most lipid parameters vs. uptitration of atorvastatin in patients ≥ 75 years (n = 228), generally consistent with patients 65–74 years (n = 812). More patients achieved LDL-C targets with combination therapy vs. monotherapy in both age groups at 6 wk and in patients ≥ 75 years at 12 wk. At 12 wk, more patients ≥ 75 years achieved LDL-C targets with monotherapy vs. combination therapy. EZ/Atorva produced more favorable improvements in most lipids vs. doubling or quadrupling the atorvastatin dose in patients ≥ 75 years, generally consistent with the findings in patients 65–74 years.

Conclusions

Our results extended previous findings demonstrating that ezetimibe added to a statin provided a generally well-tolerated therapeutic option for improving the lipid profile in patients 65 to 74 years and ≥ 75 years of age.

LDL cholesterol targets--how low to go?

PURPOSE OF REVIEW

Lowering LDL cholesterol (LDL-C) reduces vascular risk. Current guidelines recommend initiating statin therapy in patients with a yearly coronary heart disease risk of around 1.5-2%, and most clinicians prescribe standard statin regimens (e.g. 40 mg simvastatin daily). However, there is some uncertainty about whether patients at somewhat lower vascular risk should receive lipid-lowering therapy and also how intensive statin treatment should be.

RECENT FINDINGS

Lowering LDL-C by around 1 mmol/l reduces vascular mortality and major morbidity by about one-fifth, and more recent randomized trials comparing intensive versus standard statin regimens confirm that a further LDL-C reduction of 0.5 mmol/l results in an additional 15% reduction in the risk of a major vascular event. Furthermore, statin therapy significantly reduces vascular mortality and morbidity in patients with less than 1% annual risk of a major vascular event. In general, statins are safe and well tolerated, but 80 mg simvastatin is associated with an unacceptably high risk of statin-induced myopathy.

SUMMARY

Lipid-lowering therapy with statins is cost-effective for a wider range of patients than currently recommended. Intensive statin therapy is associated with larger reductions in vascular risk, and lower LDL-C targets (particularly for higher-risk individuals) should help reduce vascular mortality and major vascular morbidity substantially.

Impact of age and sex on primary preventive treatment for cardiovascular disease in the West Midlands, UK: cross sectional study

OBJECTIVES

To establish the impact of age and sex on primary preventive treatment for cardiovascular disease in a typical primary care population.

DESIGN

Cross sectional study of anonymised patient records.

PARTICIPANTS

All 41,250 records of patients aged ≥ 40 registered at 19 general practices in the West Midlands, United Kingdom, were extracted and analysed.

MAIN OUTCOME MEASURES

Patients' demographics, risk factors for cardiovascular disease (blood pressure, total cholesterol concentration), and prescriptions for primary preventive drugs were extracted from patients' records. Patients were subdivided into five year age bands up to 85 (patients aged ≥ 85 were analysed as one group) and prescribing trends across the population were assessed by estimating the proportion of patients prescribed with antihypertensive drug or statin drug, or both, in each group.

RESULTS

Of the 41,250 records screened in this study, 36,679 (89%) patients did not have a history of cardiovascular disease and therefore could be considered for primary preventive treatment. The proportion receiving antihypertensive drugs increased with age (from 5% (378/6978) aged 40-44 to 57% (621/1092) aged ≥ 85) as did the proportion taking statins up to the age of 74 (from 3% (201/6978) aged 40-44 to 29% (675/2367) aged 70-74). In those aged 75 and above, the odds of a receiving prescription for a statin (relative to the 40-44 age group) decreased with every five year increment in age (odds ratio 12.9 (95% confidence interval 10.8 to 15.3) at age 75-79 to 5.7 (4.6 to 7.2) at age ≥ 85; P<0.001). There were no consistent differences in prescribing trends by sex.

CONCLUSIONS

Previously described undertreatment of women in secondary prevention of cardiovascular disease was not observed for primary prevention. Low use of statins in older people highlights the need for a stronger evidence base and clearer guidelines for people aged over 75.

A simple strategy for screening for glucose intolerance, using glycated haemoglobin, in individuals admitted with acute coronary syndrome

Glucose intolerance is common but often remains undiagnosed and untreated in people with acute coronary syndrome. The best approach to screening for glucose intolerance post-acute coronary syndrome remains debated. The World Health Organization has recently advocated the use of HbA(1c) in diagnosing Type 2 diabetes. A screening strategy using HbA(1c) as the preferred test would be pragmatic and improve early detection and management of glucose intolerance in acute coronary care practice. In this commentary, we discuss the relevant literature and guidelines in this area and propose a simple and pragmatic algorithm based on the use of HbA(1c) to screen for glucose intolerance during and after admission with acute coronary syndrome.

New directions in cardiovascular risk assessment: the role of secondary risk stratification markers

Cardiovascular disease (CVD) risk screening is performed by multivariate methods relying on calculators derived from the Framingham study, other epidemiological studies or primary care records. However, it only identifies 70% of individuals at risk for CVD events and there has been interest in adding other risk factors to improve its predictive capacity. The addition of a family history of premature CVD is well established and there is evidence for adding lipoprotein (a) in some populations and possibly C-reactive protein may be suitable for general use in CVD risk assessment. Most new biochemical and imaging markers have been assessed in the context of improving risk classification in intermediate-risk groups rather than in the general population. There is evidence that N-terminal pro-B-type natriuretic peptide and coronary artery calcium score add significantly to risk prediction. The data for carotid intima-media thickness, ankle-brachial index are less strong and high sensitivity troponins look promising, but have had only limited data to date. Large scale meta-analyses ideally of pooled primary patient data will be required to determine the best additional markers to add to conventional risk prediction and in what groups to apply them.

Inclusion of stroke in cardiovascular risk prediction instruments: a statement for healthcare professionals from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

Current US guideline statements regarding primary and secondary cardiovascular risk prediction and prevention use absolute risk estimates to identify patients who are at high risk for vascular disease events and who may benefit from specific preventive interventions. These guidelines do not explicitly include patients with stroke, however. This statement provides an overview of evidence and arguments supporting (1) the inclusion of patients with stroke, and atherosclerotic stroke in particular, among those considered to be at high absolute risk of cardiovascular disease and (2) the inclusion of stroke as part of the outcome cluster in risk prediction instruments for vascular disease.

METHODS AND RESULTS

Writing group members were nominated by the committee co-chairs on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee and the AHA Manuscript Oversight Committee. The writers used systematic literature reviews (covering the period from January 1980 to March 2010), reference to previously published guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and, when appropriate, formulate recommendations using standard AHA criteria. All members of the writing group had the opportunity to comment on the recommendations and approved the final version of this document. The guideline underwent extensive AHA internal peer review, Stroke Council leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee. There are several reasons to consider stroke patients, and particularly patients with atherosclerotic stroke, among the groups of patients at high absolute risk of coronary and cardiovascular disease. First, evidence suggests that patients with ischemic stroke are at high absolute risk of fatal or nonfatal myocardial infarction or sudden death, approximating the ≥20% absolute risk over 10 years that has been used in some guidelines to define coronary risk equivalents. Second, inclusion of atherosclerotic stroke would be consistent with the reasons for inclusion of diabetes mellitus, peripheral vascular disease, chronic kidney disease, and other atherosclerotic disorders despite an absence of uniformity of evidence of elevated risks across all populations or patients. Third, the large-vessel atherosclerotic subtype of ischemic stroke shares pathophysiological mechanisms with these other disorders. Inclusion of stroke as a high-risk condition could result in an expansion of ≈10% in the number of patients considered to be at high risk. However, because of the heterogeneity of stroke, it is uncertain whether other stroke subtypes, including hemorrhagic and nonatherosclerotic ischemic stroke subtypes, should be considered to be at the same high levels of risk, and further research is needed. Inclusion of stroke with myocardial infarction and sudden death among the outcome cluster of cardiovascular events in risk prediction instruments, moreover, is appropriate because of the impact of stroke on morbidity and mortality, the similarity of many approaches to prevention of stroke and these other forms of vascular disease, and the importance of stroke relative to coronary disease in some subpopulations. Non-US guidelines often include stroke patients among others at high cardiovascular risk and include stroke as a relevant outcome along with cardiac end points.

CONCLUSIONS

Patients with atherosclerotic stroke should be included among those deemed to be at high risk (≥20% over 10 years) of further atherosclerotic coronary events. Inclusion of nonatherosclerotic stroke subtypes remains less certain. For the purposes of primary prevention, ischemic stroke should be included among cardiovascular disease outcomes in absolute risk assessment algorithms. The inclusion of atherosclerotic ischemic stroke as a high-risk condition and the inclusion of ischemic stroke more broadly as an outcome will likely have important implications for prevention of cardiovascular disease, because the number of patients considered to be at high risk would grow substantially.

Trends in cardiovascular disease biomarkers and their socioeconomic patterning among adults in the Scottish population 1995 to 2009: cross-sectional surveys

OBJECTIVES

To examine secular and socioeconomic changes in biological cardiovascular disease risk factor and biomarker prevalences in the Scottish population. This could contribute to an understanding of why the decline in coronary heart disease mortality in Scotland has recently stalled along with persistence of associated socioeconomic inequalities.

DESIGN

Cross-sectional surveys.

SETTING

Scotland.

PARTICIPANTS

Scottish Health Surveys: 1995, 1998, 2003, 2008 and 2009 (6190, 6656, 5497, 4202 and 4964 respondents, respectively, aged 25-64 years).

PRIMARY OUTCOME MEASURES

Gender-stratified, age-standardised prevalences of obesity, hypertension, hypercholesterolaemia and low high-density lipoprotein cholesterol blood concentration as well as elevated fibrinogen and C reactive protein concentrations according to education and social class groupings. Inequalities were assessed using the slope index of inequality, and time trends were assessed using linear regression.

RESULTS

The prevalence of obesity, including central obesity, increased between 1995 and 2009 among men and women, irrespective of socioeconomic position. In 2009, the prevalence of obesity (defined by body mass index) was 29.8% (95% CI 27.9% to 31.7%) for men and 28.2% (26.3% to 30.2%) for women. The proportion of individuals with hypertension remained relatively unchanged between 1995 and 2008/2009, while the prevalence of hypercholesterolaemia declined in men from 79.6% (78.1% to 81.1%) to 63.8% (59.9% to 67.8%) and in women from 74.1% (72.6% to 75.7%) to 66.3% (62.6% to 70.0%). Socioeconomic inequalities persisted over time among men and women for most of the biomarkers and were particularly striking for the anthropometric measures when stratified by education.

CONCLUSIONS

If there are to be further declines in coronary heart disease mortality and reduction in associated inequalities, then there needs to be a favourable step change in the prevalence of cardiovascular disease risk factors. This may require radical population-wide interventions.

Diagnostic triage and the role of natriuretic peptide testing and echocardiography for suspected heart failure: an appropriateness ratings evaluation by UK GPs

BACKGROUND

Some UK GPs are acquiring access to natriuretic peptide (NP) testing or echocardiography as diagnostic tests for heart failure. This study developed appropriateness ratings for the diagnostic application of these tests in routine general practice.

AIM

To develop appropriateness ratings for the diagnostic application of NP testing or echocardiography for heart failure in general practice.

DESIGN AND SETTING

An appropriateness ratings evaluation in UK general practice.

METHOD

Four presenting symptoms (cough, bilateral ankle swelling, dyspnoea, fatigue), three levels of risk of cardiovascular disease (low, intermediate, high), and dichotomous categorisations of cardiovascular/chest examination and electrocardiogram result, were used to create 540 appropriateness scenarios for patients in whom NP testing or echocardiography might be considered. These were rated by a 10-person expert panel, consisting of GPs and GPs with specialist interests in cardiology, in a two-round RAND Appropriateness Method.

RESULTS

Onward referral for NP testing or echocardiography was rated as an appropriate next step in 217 (40.2%) of the 540 scenarios; in 194 (35.9%) it was rated inappropriate. The ratings also show where NP testing or echocardiography were ranked as equivalent next steps and when one test was seen as the more appropriate than the other.

CONCLUSION

NP testing should be the routine test for suspected heart failure where referral for diagnostic testing is considered appropriate. An abnormal electrocardiogram status makes referral to echocardiography an accompanying, or more appropriate, next step alongside NP testing, especially in the presence of dyspnoea. Abnormal NP testing should subsequently be followed up with referral for echocardiography.

Attainment of normal lipid levels among patients on lipid-modifying therapy in Hong Kong

INTRODUCTION

Although low-density lipoprotein cholesterol (LDL-C) is the primary lipid target for coronary heart disease (CHD) risk reduction, high-density lipoprotein cholesterol (HDL-C) and triglycerides (TG) have also emerged as CHD risk factors. The objective of this study was to evaluate attainment of lipid goals and normal levels following lipid-modifying therapy (LMT) and its predictors in a representative sample of Chinese patients from Hong Kong.

METHODS

Using longitudinal data collected from patient medical records, the study identified 706 patients who initiated LMT from January 2004 to December 2006 and had full lipid panels 12 months before and after therapy. LDL-C goals and normal levels of HDL-C and TG were defined according to the National Cholesterol Education Program Adult Treatment Panel 3 guidelines. Patients with previous CHD, diabetes, and 10-year CHD risk > 20% were classified as high risk. Multiple logistic regressions evaluated predictors of normal lipid-level attainment.

RESULTS

Among 706 patients (mean age 64.6 years, 58.6% male), 71.7% had elevated LDL-C, 32.4% had low HDL-C, and 24.9% had elevated TG before LMT. Despite therapy (91.2% statins only), 22.7% had elevated LDL-C, 31.9% had low HDL-C, 12.3% had elevated TG, and 13.9% had multiple abnormal lipid levels. The strongest predictors of attaining ≥ 2 normal lipid levels included male gender (odds ratio [OR]: 2.11 [1.12 to 4.01]), diabetes (OR: 0.43 [0.23 to 0.78]), obesity (OR: 0.91 [0.86 to 0.97]), and CHD risk > 20% (OR: 0.33 [0.15 to 0.71]).

CONCLUSIONS

Current approaches to lipid management in Hong Kong, primarily using statins, considerably improve attainment of LDL-C goal. However, a large proportion of patients do not achieve normal HDL-C levels and control of multiple lipid parameters remains poor. Patients could benefit from a more comprehensive approach to lipid management that treats all three lipid risk factors, as suggested in clinical guidelines.

Beyond beliefs: risk assessment technologies shaping patients' experiences of heart disease prevention

Social science research on lifestyle-related diseases typically focuses on patients' understandings and beliefs and takes the clinical risk for granted. We interviewed 30 healthy UK patients at high risk of heart disease, recruited from a family history trial at 2 weeks and 6 months after a discussion with a clinician about their risk, lifestyle and medications. The participants took four different paths: (i) pharmaceutical (most common, risk reduction with cholesterol lowering statins), (ii) mixed (statins and behaviour change), (iii) behavioural (behaviour change, focus on wellbeing) and (iv) 'lost' (no prevention, difficult social/personal circumstances). Drawing on Berg we argue that coronary heart disease (CHD) risk assessment technologies are formal tools that generate, rather than represent, high risk in a way that patients often experience lifestyle change as futile, because it rarely reduces their cholesterol to targets defined by the tools. We suggest social scientists studying incipient or 'proto-diseases', such as CHD risk, should not only focus on understandings but also investigate the technologies (and the associated guidelines, policies, clinical practice and pharmaceutical industry operations) that generate incipient diseases and patients' experiences of them. However, technologies do not determine experience and we also discuss elements that direct patients down other than the pharmaceutical path.

Evaluation of serum adipokines in peripheral arterial occlusive disease

Aim. Out study aimed to assess the serum levels of adipokines in patients with peripheral arterial occlusive disease (PAOD) caused by atherosclerosis. Methods. Serum samples were obtained from 221 patients. One hundred and forty patients, (26 females and 114 males) met the inclusion criteria and were assigned into the case group. Eighty one patients (17 females and 64 males), were included in the control group. Circulating plasma levels of adiponectin, leptin, resistin, and TNF-α were measured using the enzyme-linked immunosorbent assay (ELISA) method. Results. Significant lower levels of adiponectin were present (P = 0.0061) in PAOD patients (2380.23 ± 1634.42 pg/mL) compared to the control group (3065.06 ± 1901.2 pg/mL). The mean value of leptin (2844.42 ± 3301.08 pg/mL) and resistin (2047.81±3301.08 pg/mL) patients included in the PAOD group was higher, as compared to the control group. Statistically significant difference was found between the two groups for leptin (P = 0.0332) and for resistin (P = 0.0352). No statistically significant difference for TNF-α was found between the two groups (P > 0.05). Conclusion. The markers of inflammation secreted by the adipose tissue (adiponectin, leptin, resistin) showed significant differences in patients from the case group (with PAOD) compared to the control group.

Non-steroidal anti-inflammatory drugs for the treatment of pain and immobility-associated osteoarthritis: consensus guidance for primary care

Background

Osteoarthritis is a common presentation in primary care, and non-selective non-steroidal anti-inflammatory drugs (sometimes also referred to as traditional NSAIDs or tNSAIDs) and selective cyclo-oxygenase 2 inhibitors (COX-2 inhibitors) are commonly used to treat it. The UK's National Institute for Health and Clinical Excellence (NICE) recommends taking patient risk factors into account when selecting a tNSAID or a COX-2 inhibitor, but GPs have lacked practical guidance on assessing patient risk.

Methods

A multi-disciplinary group that included primary care professionals (PCPs) developed an evidence-based consensus statement with an accompanying flowchart that aimed at providing concise and specific guidance on NSAID use in osteoarthritis treatment. An open invitation to meet and discuss the issue was made to relevant healthcare professionals in South Yorkshire. A round table meeting was held that used a modified nominal group technique, aimed at generating opinions and ideas from all stakeholders in the consensus process. A draft developed from this meeting went through successive revisions until a consensus was achieved.

Results

Four statements on the use of tNSAIDs and COX-2 inhibitors (and an attached category of evidence) were agreed: 1) tNSAIDs are effective drugs in relieving pain and immobility associated with osteoarthritis. COX-2 inhibitors are equally effective; 2) tNSAIDs and COX-2 inhibitors vary in their potential gastrointestinal, liver, and cardio-renal toxicity. This risk varies between individual treatments within both groups and is increased with dose and duration of treatment; 3) COX-2 inhibitors are associated with a significantly lower gastrointestinal toxicity compared to tNSAIDs. Co-prescribing of aspirin reduces this advantage; 4) PPIs should always be considered with a tNSAID and with a COX-2 inhibitor in higher GI risk patients. An accompanying flowchart to guide management was also agreed.

Conclusions

Individual patient risk is an important factor in choice of treatment for patients with osteoarthritis and the consensus statement developed offers practical guidance for GPs and others in primary care. Where there are clinical uncertainties, guidance developed and agreed by local clinicians has a role to play in improving patient management.

The difference in blood pressure readings between arms and survival: primary care cohort study

OBJECTIVE

To determine whether a difference in systolic blood pressure readings between arms can predict a reduced event free survival after 10 years.

DESIGN

Cohort study.

SETTING

Rural general practice in Devon, United Kingdom.

PARTICIPANTS

230 people receiving treatment for hypertension in primary care.

INTERVENTION

Bilateral blood pressure measurements recorded at three successive surgery attendances.

MAIN OUTCOME MEASURES

Cardiovascular events and deaths from all causes during a median follow-up of 9.8 years.

RESULTS

At recruitment 24% (55/230) of participants had a mean interarm difference in systolic blood pressure of 10 mm Hg or more and 9% (21/230) of 15 mm Hg or more; these differences were associated with an increased risk of all cause mortality (adjusted hazard ratio 3.6, 95% confidence interval 2.0 to 6.5 and 3.1, 1.6 to 6.0, respectively). The risk of death was also increased in 183 participants without pre-existing cardiovascular disease with an interarm difference in systolic blood pressure of 10 mm Hg or more or 15 mm Hg or more (2.6, 1.4 to 4.8 and 2.7, 1.3 to 5.4). An interarm difference in diastolic blood pressure of 10 mm Hg or more was weakly associated with an increased risk of cardiovascular events or death.

CONCLUSIONS

Differences in systolic blood pressure between arms can predict an increased risk of cardiovascular events and all cause mortality over 10 years in people with hypertension. This difference could be a valuable indicator of increased cardiovascular risk. Bilateral blood pressure measurements should become a routine part of cardiovascular assessment in primary care.

New lipid-lowering drugs: an update

Lipid lowering is established as a proven intervention to reduce atherosclerosis and its complications. Statins form the basis of care but are not able to treat all aspects of dyslipidaemia. Many novel therapeutic compounds are being developed. These include additional therapeutics for low-density lipoprotein cholesterol, for example, thyroid mimetics (thyroid receptor beta-agonists), antisense oligonucleotides or microsomal transfer protein inhibitors (MTPI); triglycerides, for example, novel peroxosimal proliferator activating receptors agonists, MTPIs, diacylglycerol acyl transferase-1 inhibitors and high-density lipoprotein cholesterol (HDL-C), for example, mimetic peptides; HDL delipidation strategies and cholesterol ester transfer protein inhibitors and modulators of inflammation, for example, phospholipase inhibitors. Gene therapy for specific rare disorders, for example, lipoprotein lipase deficiency using alipogene tiparvovec is also in clinical trials. Lipid-lowering drugs are likely to prove a fast-developing area for novel treatments as possible synergies exist between new and established compounds for the treatment of atherosclerosis.

Daily and intermittent rosuvastatin 5 mg therapy in statin intolerant patients: an observational study

OBJECTIVE

To examine the efficacy and tolerability of rosuvastatin 5 mg at daily and non-daily dosing regimens.

RESEARCH DESIGN AND METHODS

A retrospective survey was conducted at nine primary, secondary and tertiary healthcare centres in the United Kingdom.

MAIN OUTCOME MEASURES

Changes in lipid fractions from baseline values after more than 3 months' treatment.

RESULTS

A total of 325 patients were identified. These patients were aged 63 ± 10 years, 50% male and prescription was mostly for primary prevention of cardiovascular disease (CVD) (59%). Co-morbidities included: established CVD present in 41%, type 2 diabetes mellitus (15%), hypertension (74%) and smoking (9%). Adverse effects had been documented to simvastatin (75%) or atorvastatin (63%). A total of 289 patients (89%) tolerated rosuvastatin well and were still adherent after a median follow-up of 14.9 (3-79) months. The remainder (n = 36; 11%) discontinued the medication after median 5 months' treatment due to adverse effects. Efficacy was assessed in 224 patients who had adequate data. Baseline lipids were total cholesterol (TC) 7.41 ± 1.50 mmol/L, triglycerides (TG) 2.26 (range 0.36-18.4) mmol/L; high density lipoprotein cholesterol (HDL-C) 1.43 ± 0.47 mmol/L and low density lipoprotein cholesterol (LDL-C) 4.76 ± 1.38 mmol/L. Daily rosuvastatin (n = 134) reduced mean TC by 31%, TG 15% and LDL-C 43% (p < 0.001). Rosuvastatin 5 mg 2-3 times weekly (n = 79) reduced TC 26%, TG 16% and LDL-C 32% (p < 0.001). Weekly rosuvastatin (n = 11) reduced TC 17%, LDL-C by 23% (p < 0.001) but had no effect on TGs. Targets were attained in 17% of CHD-risk equivalent patients and 41% of primary prevention patients by National Cholesterol Education Program criteria and 27% and 68% using UK targets. No myositis or rhabdomyolysis was observed and alanine aminotransferase (ALT) and creatine kinase (CK) were similar to baseline.

CONCLUSIONS

In this retrospective observational multicentre study, rosuvastatin 5 mg was found to be safe and biochemically effective either as daily or intermittent therapy in patients intolerant to other conventional statin regimens.

Patient and other factors influencing the prescribing of cardiovascular prevention therapy in the general practice setting with and without nurse assessment

BACKGROUND

Although guidelines indicate when patients are eligible for antihypertensives and statins, little is known about whether general practitioners (GPs) follow this guidance.

OBJECTIVE

To determine the factors influencing GPs decisions to prescribe cardiovascular prevention drugs.

DESIGN OF STUDY

Secondary analysis of data collected on patients whose cardiovascular risk factors were measured as part of a controlled study comparing nurse-led risk assessment (four practices) with GP-led risk assessment (two practices).

SETTING

Six general practices in the West Midlands, England.

PATIENTS

Five hundred patients: 297 assessed by the project nurse, 203 assessed by their GP.

MEASUREMENTS

Cardiovascular risk factor data and whether statins or antihypertensives were prescribed. Multivariable logistic regression models investigated the relationship between prescription of preventive treatments and cardiovascular risk factors.

RESULTS

Among patients assessed by their GP, statin prescribing was significantly associated only with a total cholesterol concentration ≥ 7 mmol/L and antihypertensive prescribing only with blood pressure ≥ 160/100 mm Hg. Patients prescribed an antihypertensive by their GP were five times more likely to be prescribed a statin. Among patients assessed by the project nurse, statin prescribing was significantly associated with age, sex, and all major cardiovascular risk factors. Antihypertensive prescribing was associated with blood pressures ≥ 140/90 mm Hg and with 10-year cardiovascular risk.

LIMITATIONS

Generalizability is limited, as this is a small analysis in the context of a specific cardiovascular prevention program.

CONCLUSIONS

GP prescribing of preventive treatments appears to be largely determined by elevation of a single risk factor. When patients were assessed by the project nurse, prescribing was much more consistent with established guidelines.

Rosuvastatin and atorvastatin: comparative effects on glucose metabolism in non-diabetic patients with dyslipidaemia

The ever increasing interventional CVD outcome studies have resulted in statins being an essential factor of cardiovascular prevention strategies. The JUPITER study in 2008, despite reducing CVD and overall mortality, highlighted an increase in new onset diabetes in the rosuvastatin treated arm. Since then there have been many meta-analyses of the RCTs and the largest carried out by Sattar et al showed a significant increase in the incidence of diabetes during the trials. The findings from the individual studies when comparing the different statins were less clear. A higher statin dosage and risk factors associated with diabetes appeared to predict this phenomenon. There have been many studies investigating the effects of statins on glycaemic control, but again no clear conclusion is apparent. Despite the increase in new onset diabetes observed, the risk is clearly out-weighed by the CVD benefits observed in nearly all the statin trials. Thus, no change is required to any of the prevention guidelines regarding statins. However, it may be prudent to monitor glycaemic control after commencing statin therapy. This review will focus on atorvastatin which is the most widely used statin worldwide and rosuvastatin which is the most efficacious. This will be against a background of the effects of other statins on glucose metabolism in non-diabetic patients.

Effects of combined aspirin and clopidogrel therapy on cardiovascular outcomes: a systematic review and meta-analysis

BACKGROUND

Aspirin and clopidogrel monotherapies are effective treatments for preventing vascular disease. However, new evidence has emerged regarding the use of combined aspirin and clopidogrel therapy to prevent cardiovascular events. We therefore performed a comprehensive systematic review and meta-analysis to evaluate the benefits and harms of combined aspirin and clopidogrel therapy on major cardiovascular outcomes.

METHODOLOGY/PRINCIPAL FINDINGS

We systematically searched Medline, Embase, the Cochrane Central Register of Controlled Trials, reference lists of articles, and proceedings of major meetings to identify studies to fit our analysis. Eligible studies were randomized controlled trials assessing the effect of combined aspirin and clopidogrel therapy compared with aspirin or clopidogrel monotherapy. We identified 7 trials providing data with a total of 48248 patients. These studies reported 5134 major cardiovascular events, 1626 myocardial infarctions, 1927 strokes, and 1147 major bleeding events. Overall, the addition of aspirin to clopidogrel therapy as compared to single drug therapy resulted in a 9% RR reduction (95%CI, 2 to 17) in major cardiovascular events, 14% RR reduction (95%CI, 3 to 24) in myocardial infarction, 16% RR reduction (95%CI, 1 to 28) in stroke, and 62% RR increase (95%CI, 26 to 108) in major bleeding events. We also present the data as ARR to explore net value as the reduction in cardiovascular events. Overall, we observed that combined therapy yielded 1.06% decrease (95%CI, 0.23% to 1.99%) in major cardiovascular events and 1.23% increase (95%CI, 0.52% to 2.14%) in major bleeding events.

CONCLUSION/SIGNIFICANCE

Although the addition of aspirin to clopidogrel resulted in small relative reductions in major cardiovascular events, myocardial infarction, and stroke, it also resulted in a relative increase in major bleeding events. In absolute terms the benefits of combined therapy, a 1.06% reduction in major cardiovascular events, does not outweigh the harms, a 1.23% increase in major bleeding events.

Connected health care: the future of health care and the role of the pharmacist

The population of the world is ageing. As a result, the incidence of chronic disease is projected to increase, there are predicted shortages in health care workforce and budget restraints; implications for future health care provision are serious. The current model of health care is not equipped to deal with these changes. Connected health care, via the use of health informatics, disease management and home telehealth technologies, has been suggested as an approach to ease the projected strain on future health care. Evidence to date suggests a positive impact of the use of connected health care model; however, the majority of studies have overlooked the involvement of the community pharmacist. As the most common point of contact with primary health services for most of the population, the community pharmacist may be well placed to provide connected health care. The research to date is promising with improvements in outcomes for cardiovascular patients noted; however, further work is required to investigate the potential role the community pharmacist can play in the future of connected health care.

Human health effects of conjugated linoleic acid from milk and supplements

The primary purpose of the present review was to determine if the scientific evidence available for potential human health benefits of conjugated linoleic acid (CLA) is sufficient to support health claims on foods based on milk naturally enriched with cis-9, trans-11-CLA (c9, t11-CLA). A search of the scientific literature was conducted and showed that almost all the promising research results that have emerged in relation to cancer, heart health, obesity, diabetes and bone health have been in animal models or in vitro. Most human intervention studies have utilised synthetic CLA supplements, usually a 50:50 blend of c9, t11-CLA and trans-10, cis-12-CLA (t10, c12-CLA). Of these studies, the only evidence that is broadly consistent is an effect on body fat and weight reduction. A previous review of the relevant studies found that 3.2 g CLA/d resulted in a modest body fat loss in human subjects of about 0.09 kg/week, but this effect was attributed to the t10, c12-CLA isomer. There is no evidence of a consistent benefit of c9, t11-CLA on any health conditions; and in fact both synthetic isomers, particularly t10, c12-CLA, have been suspected of having pro-diabetic effects in individuals who are already at risk of developing diabetes. Four published intervention studies using naturally enriched CLA products were identified; however, the results were inconclusive. This may be partly due to the differences in the concentration of CLA administered in animal and human studies. In conclusion, further substantiation of the scientific evidence relating to CLA and human health benefits are required before health claims can be confirmed.

A framework for quantifying net benefits of alternative prognostic models

New prognostic models are traditionally evaluated using measures of discrimination and risk reclassification, but these do not take full account of the clinical and health economic context. We propose a framework for comparing prognostic models by quantifying the public health impact (net benefit) of the treatment decisions they support, assuming a set of predetermined clinical treatment guidelines. The change in net benefit is more clinically interpretable than changes in traditional measures and can be used in full health economic evaluations of prognostic models used for screening and allocating risk reduction interventions. We extend previous work in this area by quantifying net benefits in life years, thus linking prognostic performance to health economic measures; by taking full account of the occurrence of events over time; and by considering estimation and cross-validation in a multiple-study setting. The method is illustrated in the context of cardiovascular disease risk prediction using an individual participant data meta-analysis. We estimate the number of cardiovascular-disease-free life years gained when statin treatment is allocated based on a risk prediction model with five established risk factors instead of a model with just age, gender and region. We explore methodological issues associated with the multistudy design and show that cost-effectiveness comparisons based on the proposed methodology are robust against a range of modelling assumptions, including adjusting for competing risks.

Peripheral arterial disease: a literature review

INTRODUCTION

Peripheral arterial disease (PAD) is a common vascular condition that affects both quality of life and life expectancy with an increased risk of cardiovascular events.

SOURCES OF DATA

A literature search was carried out of Pub-Med, MEDLINE, the Cochrane Library and Google Scholar from the establishment of these databases up to February 2012. The search was performed by using the keywords 'peripheral arterial disease' and one of the following words: 'management', 'investigations', 'risk factors', 'epidemiology', 'revascularization', 'cryoplasty', 'atherectomy' and 'gene therapy'. Studies were limited to those published in English language.

AREAS OF AGREEMENT

Aggressive risk factors modification is needed to reduce cardiovascular-related mortality in PAD patients.

AREAS OF CONTROVERSY

Choice of endovascular or surgical intervention remains controversial in an ever-evolving field.

GROWING POINTS

There is a rapid expansion of endovascular technologies aiming to improve the effectiveness of this modality.

AREAS TIMELY FOR DEVELOPING RESEARCH

The advances in the fields of gene therapy and therapeutic angiogenesis mean these are potential future treatments. Tissue engineering is a developing area and aims to produce grafts with similar patency and infection profiles to those of autologous material. Further elucidation of the pathophysiology of atherosclerosis is required to provide new targets for pharmacotherapy.

Cardiovascular risk factors in patients with schizophrenia receiving continuous medical care

Modifiable risk factors for cardiovascular disease were assessed among individuals with schizophrenia receiving continuous (i.e. 24-h) medical care. Participants tended to have higher levels of risk factors than for the general population. They had similar levels of risk factors as for previous UK studies of patients not receiving continuous care, except they tended to have higher smoking rates and lower physical activity levels, although statistical comparisons were not possible. Among patients with schizophrenia receiving continuous medical care interventions for health behavior change may need to be further prioritized and there is a need to capitalize on the ready availability of social support in these settings.

How to stay heart healthy in 2011: considerations for the primary prevention of cardiovascular disease in women

More women die of cardiovascular disease than any other cause. Effective primary prevention depends on accurate assessment of risk status. While most risk factors are similar for men and women, risk factors may differ in magnitude between the sexes, and recognition of gender-specific risk factors such as gestational diabetes, hypertensive syndromes of pregnancy and polycystic ovarian syndrome provides opportunities for early intervention and prevention. Obesity, hypertension and hyperlipidemia affect both genders; however, women often postpone addressing these risk factors until later in life. The American Heart Association emphasizes that all women are at cardiovascular risk and should maintain a healthy lifestyle and avoid smoking. Blood pressure, hyperlipidemia and diabetes should be aggressively treated. Current available data regarding proposed preventive drug therapies including daily aspirin, HRT, vitamin D and omega-3 fatty acid supplements will be reviewed.

Rheumatoid arthritis: is it a coronary heart disease equivalent?

PURPOSE OF REVIEW

This review examines current evidence to address the question whether rheumatoid arthritis (RA) is a coronary heart disease equivalent, similar to type 2 diabetes mellitus (DM2).

RECENT FINDINGS

Cross-sectional and longitudinal epidemiological studies show a two-fold higher risk of cardiovascular disease (CVD) in patients with RA, and the magnitude of this increased risk is comparable to the risk associated with DM2. However, the mechanisms responsible for this appear to be different in the two conditions, with RA-related CVD being attributed to 'high-grade' systemic inflammation as well as classical CVD risk factors. Several classical risk factors are affected by RA or its medications, and there are some paradoxical associations between obesity or lipid abnormalities and CVD death in RA.

SUMMARY

Management of RA-related CVD is likely to require both aggressive control of inflammation and systematic screening and management of classical CVD risk factors. It remains unknown whether primary prevention strategies applied successfully in DM2 would be equally easy to implement and demonstrate similar benefits in people with RA.

Framingham risk prediction equations for incidence of cardiovascular disease using detailed measures for smoking

Current prediction models for risk of cardiovascular disease (CVD) incidence incorporate smoking as a dichotomous yes/no measure. However, the risk of CVD associated with smoking also varies with the intensity and duration of smoking and there is a strong association between time since quitting and the risk of disease onset. This study aims to develop improved risk prediction equations for CVD incidence incorporating intensity and duration of smoking and time since quitting.

The risk of developing a first CVD event was evaluated using a Cox’s model for participants in the Framingham offspring cohort who attended the fourth examination (1988–92) between the ages of 30 and 74 years and were free of CVD (n=3751). The full models based on the smoking variables and other risk factors, and reduced models based on the smoking variables and non-laboratory risk factors demonstrated good discrimination, calibration and global fit. The incorporation of both time since quitting among past smokers and pack-years among current smokers resulted in better predictive performance as compared to a dichotomous current/non-smoker measure and a current/quitter/never smoker measure. Compared to never smokers, the risk of CVD incidence increased with pack-years. Risk among those quitting more than five years prior to the baseline exam and within five years prior to the baseline exam were similar and twice as high as that of never smokers. A CVD risk equation incorporating the effects of pack-years and time since quitting provides an improved tool to quantify risk and guide preventive care.

Cardiovascular risk among Aboriginal and non-Aboriginal smoking male prisoners: inequalities compared to the wider community

Background

Cardiovascular risk factors (CVRF) were collected as part of a randomised controlled trial of a multi-component intervention to reduce smoking among male prisoners. Cross-sectional baseline data on CVRF were compared among smoking male prisoners and males of similar age in the general population.

Methods

425 smoking prisoners were recruited (n = 407 in New South Wales; 18 in Queensland), including 15% of Aboriginal descent (mean age 33 years; median sentence length 3.6 years). We measured CVRF such as smoking, physical activity, blood pressure, risky alcohol use, symptoms of depression, and low socioeconomic status.

Results

We found that 39% of prisoners had 3+ CVRF, compared to 10% in a general community sample of most disadvantaged men of a similar age. Significantly more Aboriginal prisoners had 3+ CVRF than non-Aboriginal prisoners (55% vs 36%, p < 0.01) and were twice as likely to have 4+ CVRF (27% vs 12%). In addition to all prisoners in this study being a current smoker (with 70% smoking 20+ cigarettes per day), the prevalence of other CVRF was very high: insufficient physical activity (23%); hypertension (4%), risky drinking (52%), symptoms of depression (14%) and low socioeconomic status (SES) (44%). Aboriginal prisoners had higher levels of risky alcohol use, symptoms of depression, and were more likely to be of low SES.

Conclusion

Prisoners are at high risk for developing cardiovascular disease compared to even the most disadvantaged in their community and should be the focus of specific public health interventions.

Trial Registration

This trial is registered with the Australian New Zealand Clinical Trials Registry ACTRN#12606000229572.

Prevalence of the metabolic syndrome in Danish psychiatric outpatients treated with antipsychotics

BACKGROUND

The incidence of the metabolic syndrome, a major risk factor for diabetes and cardiovascular disease, is increasing worldwide and is suggested to be higher among psychiatric patients, especially those on antipsychotic treatment.

AIMS

To assess the prevalence of the metabolic syndrome in Danish psychiatric outpatients and compare it with the general population.

METHODS

In a cross-sectional, observational study in 2007-08, 170 Danish outpatients on antipsychotic drug treatment were monitored for the prevalence of the metabolic syndrome based on the International Diabetes Federation (IDF) definition and compared with a general population group of 3303 randomly selected Danes.

RESULTS

Of the antipsychotic-treated patients 48.2% fulfilled the IDF criteria for the metabolic syndrome, compared with 29.6% of the general population. The antipsychotic-treated patients had higher rates of increased waist circumference, triglyceride and glucose levels, and lower high-density lipoprotein cholesterol. Compared with the general population, the odds ratio (OR) of the metabolic syndrome among antipsychotic-treated patients was 2.2. After adjustment for age and sex, the OR increased to 2.7. In the antipsychotic-treated group, statistically different rates of the metabolic syndrome for patients in monopharmacy vs. polypharmacy, and for patients in monotherapy with first-generation vs. second-generation antipsychotics, could not be found.

CONCLUSION

The metabolic syndrome is highly prevalent among a Danish outpatient population treated with antipsychotics compared with the general population. Monitoring of lipid and glucose levels, blood pressure and waist circumference before start-up and during treatment with antipsychotic medication is of pivotal importance in order to prevent diabetes and cardiovascular disease in this patient population.

Effects of additional blood pressure and lipid measurements on the prediction of cardiovascular risk

BACKGROUND

Current guidelines recommend that decisions to start preventative therapy for cardiovascular disease (CVD) should be based on absolute risk; however, current risk equations are based on single measurements of risk factors. We aimed to assess whether two measurements of blood pressure and lipids improves the prediction of cardiovascular risk compared to one measurement.

METHODS AND RESULTS

We used sex-specific Cox proportional hazards models to evaluate the risk of first CVD event in 2385 participants of the Framingham Offspring Study attending both the second and third visits. We estimated the effects on risk prediction of using the average of two measurements of blood pressure, total cholesterol, and HDL cholesterol compared to using one measurement of the risk factors. We found that these risk factors were each markedly more predictive of CVD when the average of two measurements was used rather than one measurement and age was less predictive of CVD. There were small improvements in the overall model fit, discrimination, and calibration. Reclassification also showed small improvements across the risk spectrum (net reclassification information, NRI, for women 3.0%, 95% CI -0.9 to 24.8%; NRI for men 4.0%, 95% CI -2.2 to 14.1%) and possibly greater improvements for intermediate-risk individuals (NRI for women 32.3%, 95% CI -21.9 to 46.8%; NRI for men 16.0%, 95% CI -3.3 to 43%).

CONCLUSIONS

Averaging two measurements of blood pressure and lipids results in marked increases in the predictiveness of these risk factors and smaller improvements in the overall prediction of cardiovascular risk including reclassification.

An evaluation of Birmingham Own Health telephone care management service among patients with poorly controlled diabetes. A retrospective comparison with the General Practice Research Database

Background

Telephone-based care management programmes have been shown to improve health outcomes in some chronic diseases. Birmingham Own Health^® is a telephone-based care service (nurse-delivered motivational coaching and support for self-management and lifestyle change) for patients with poorly controlled diabetes, delivered in Birmingham, UK. We used a novel method to evaluate its effectiveness in a real-life setting.

Methods

Retrospective cohort study in the UK. 473 patients aged ≥ 18 years with diabetes enrolled onto Birmingham Own Health^® (intervention cohort) and with > 90 days follow-up, were each matched by age and sex to up to 50 patients with diabetes registered with the General Practice Research Database (GPRD) to create a pool of 21,052 controls (control cohort). Controls were further selected from the main control cohort, matching as close as possible to the cases for baseline test levels, followed by as close as possible length of follow-up (within +/-30 days limits) and within +/-90 days baseline test date. The aim was to identify a control group with as similar distribution of prognostic factors to the cases as possible. Effect sizes were computed using linear regression analysis adjusting for age, sex, deprivation quintile, length of follow-up and baseline test levels.

Results

After adjusting for baseline values and other potential confounders, the intervention showed significant mean reductions among people with diabetes of 0.3% (95%CI 0.1, 0.4%) in HbA1c; 3.5 mmHg (1.5, 5.5) in systolic blood pressure, 1.6 mmHg (0.4, 2.7) in diastolic blood pressure and 0.7 unit reduction (0.3, 1.0) in BMI, over a mean follow-up of around 10 months. Only small effects were seen on average on serum cholesterol levels (0.1 mmol/l reduction (0.1, 0.2)). More marked effects were seen for each clinical outcome among patients with worse baseline levels.

Conclusions

Despite the limitations of the study design, the results are consistent with the Birmingham Own Health^® telephone care management intervention being effective in reducing HbA1c levels, blood pressure and BMI in people with diabetes, to a degree comparable with randomised controlled trials of similar interventions and clinically important. The effects appear to be greater in patients with poorer baseline levels and the intervention is effective in the most deprived populations.

Primary Prevention of Cardiovascular Disease

Cardiovascular disease (CVD) is a spectrum of disorders that includes stroke, coronary heart disease (CHD) and peripheral vascular disease (PVD). CVD is the UK's biggest cause of death, with over 191 000 deaths a year. The extent to which CVD affects the health of the population and the financial burden this places on the National Health Service (NHS) makes it an important modifiable disease. Preventing CVD is now a significant role of the general practice team.

Pre-hypertension: how low to go and do drugs have a role?

People with pre-hypertension (high blood pressure but below the conventional threshold for intervention with antihypertensive drugs) undoubtedly have increased risk of cardiovascular and other complications. However, the vast majority has low absolute risk and whether treatment would be beneficial is uncertain. While pharmacotherapy has attractions from a public health perspective, clinicians and crucially those with pre-hypertension require robust evidence that drug treatment will lead to short term as well as long term gains. Any changes in recommendations should await adequately powered outcome studies which provide solid evidence of the magnitude of absolute risk reduction in treating pre-hypertension and assessment of the cost-effectiveness.

Obesity and metabolic syndrome during the menopause transition in Serbian women

BACKGROUND

Abdominal obesity and metabolic syndrome are known to increase in prevalence from premenopause to postmenopause. Both are well recognized predictors of cardiovascular disease and diabetes in women. Aims The primary objective of this study was to assess the presence of obesity and metabolic syndrome during the menopause transition in Serbian women who attended health-care centers. The secondary objective was to evaluate the prevalence of ischemic heart disease, stroke and diabetes in this group.

METHODS

Our results present a part of the national epidemiological cross-sectional study assessing prevalence of metabolic syndrome and obesity in Serbia. In all, 1076 women attending 20 health-care centers were assessed. Women were divided into five groups: premenopausal, perimenopausal, early and late postmenopausal and geripausal. Medical history, waist circumference, blood glucose, lipids, and blood pressure were recorded.

RESULTS

The mean body mass index of all women was 28.5 ± 4.9 kg/m(2). The mean waist circumference of all women was 92 ± 12.5 cm. Both were significantly lower in premenopausal women than in other women. Metabolic syndrome was present in 72% of women, with a significant difference in prevalence between premenopausal women and other groups. High triglyceride levels and hypertension were the most commonly present components of metabolic syndrome. Ischemic heart disease, stroke and diabetes occurred significantly more often in postmenopausal and geripausal women.

CONCLUSION

The majority of Serbian women attending health-care centers have abdominal obesity and metabolic syndrome which significantly increase in prevalence in the perimenopausal years. This indicates that preventive measures should be focused on diabetes and cardiovascular disease in the perimenopause.

Impact of time since last caloric intake on blood glucose levels

Blood glucose (BG) is usually measured after a caloric restriction of at least 8 h; however evidence-based recommendations for the duration of a fasting status are missing. Here we analyze the effect of fasting duration on levels of BG to determine the minimal fasting duration to achieve comparable BG levels to conventional fasting measurements. We used data of a cross-sectional study on primary care patients, performed in October 2005. We included 28,024 individuals (age-range 18–99 years; 63% women) without known diabetes mellitus and without missing data for BG and fasting status. We computed general linear models, adjusting for age, sex, time of blood withdrawal, systolic blood pressure, waist circumference, total- and HDL-cholesterol, physical activity, smoking, intake of beta-blocker and alcohol. We tested the intra-individual variability with respect to fasting status. Overall, the mean BG differed only slightly between individuals fasting ≥8 h and those fasting <8 h (men: 5.1 ± 0.8 mmol/L versus 5.2 ± 1.2 mmol/L; women: 4.9 ± 0.7 mmol/L, 5.0 ± 1.0 mmol/L). After 3 h of fasting differences of BG diminished in men to −0.08 mmol/L (95%-CI: −0.15; −0.01 mmol/L), in women to −0.07 mmol/L (−0.12; −0.03 mmol/L) compared to individuals fasting ≥8 h. Noteworthy, age, time of day of blood withdrawal, physical activity, and intake of hard liquor influenced BG levels considerably. Our data challenge the necessity for a fasting duration of ≥8 h when measuring blood glucose, suggesting a random sampling or a fasting duration of 3 h as sufficient. Rather, our study indicates that essentially more effort on the assessment of additional external/internal factors on BG levels is necessary.

Effectiveness and cost effectiveness of cardiovascular disease prevention in whole populations: modelling study

OBJECTIVE

To estimate the potential cost effectiveness of a population-wide risk factor reduction programme aimed at preventing cardiovascular disease.

DESIGN

Economic modelling analysis.

SETTING

England and Wales. Population Entire population. Model Spreadsheet model to quantify the reduction in cardiovascular disease over a decade, assuming the benefits apply consistently for men and women across age and risk groups.

MAIN OUTCOME MEASURES

Cardiovascular events avoided, quality adjusted life years gained, and savings in healthcare costs for a given effectiveness; estimates of how much it would be worth spending to achieve a specific outcome.

RESULTS

A programme across the entire population of England and Wales (about 50 million people) that reduced cardiovascular events by just 1% would result in savings to the health service worth at least £30m (€34m; $48m) a year compared with no additional intervention. Reducing mean cholesterol concentrations or blood pressure levels in the population by 5% (as already achieved by similar interventions in some other countries) would result in annual savings worth at least £80m to £100m. Legislation or other measures to reduce dietary salt intake by 3 g/day (current mean intake approximately 8.5 g/day) would prevent approximately 30,000 cardiovascular events, with savings worth at least £40m a year. Legislation to reduce intake of industrial trans fatty acid by approximately 0.5% of total energy content might gain around 570,000 life years and generate NHS savings worth at least £230m a year.

CONCLUSIONS

Any intervention that achieved even a modest population-wide reduction in any major cardiovascular risk factor would produce a net cost saving to the NHS, as well as improving health. Given the conservative assumptions used in this model, the true benefits would probably be greater.

Reliance on credibility to prioritise interventions can lead to sub-optimal management strategies

When there is more than one possible intervention, clinicians have to decide which intervention to offer first. This paper hypothesises that where there is more than one intervention for which the evidence indicates there is similar effectiveness that selecting the intervention with the lowest credibility first may lead to optimal long-term results.

Treatment recommendations to prevent myocardial ischemia and infarction in patients undergoing vascular surgery

During major vascular surgery (MVS), patients are at high risk for developing unrecognized myocardial infarction (MI) and myocardial ischemia. In reducing postoperative morbidity and mortality, preoperative cardiac risk stratification and adequate medical therapy play a pivotal role. Based on literature and current opinions, medical treatment should comprise at least a combination of beta-blockers, aspirin, and statins. beta-Blockers exert their beneficial effects predominantly through heart rate control, leading to reduced oxygen demand during surgery. A heart rate between 65 and 70 bpm should be achieved. Irrespective of their lipid-lowering effects, statins seem to improve postoperative cardiac outcome by stabilizing coronary artery plaques, thereby preventing atherosclerotic plaque rupture. Aspirin reduces platelet activation and vasoconstriction, thereby limiting ischemic events and reducing nonfatal MI by 34%. Adding clopidogrel to low-dose aspirin might be beneficial toward postoperative cardiac outcomes; however, the effect on the incidence of postoperative bleeding complications may be a problem for future studies to resolve. Whereas beta-blockers inhibit the effect of catecholamines, alpha(2)-agonists inhibit catecholamine release and may be used in the perioperative setting when beta-blockers are contraindicated. Despite the blood pressure-lowering effect and anti-inflammatory properties of angiotensin-converting enzyme inhibitors, the literature does not support their use in patients undergoing MVS. The possible use of calcium antagonists before MVS should be further evaluated in high-risk patients with contraindications to beta-blockers, such as asthma, conduction abnormalities, or a history of stroke. Although nitrates are widely used for treating angina pectoris, the beneficial effect of their use in patients undergoing MVS remains controversial. Therefore, nitrates are not routinely used in the perioperative setting. The current American College of Cardiology/American Heart Association guidelines do not recommend prophylactic coronary revascularization before noncardiac surgery in patients with stable coronary artery disease.

'Waste the Waist': the development of an intervention to promote changes in diet and physical activity for people with high cardiovascular risk

OBJECTIVES

To identify an evidence-based intervention to promote changes in diet and physical activity and adapt it for a UK primary care setting for people with high cardiovascular risk.

DESIGN

A three-stage mixed-methods design was used to facilitate a strategic approach to programme selection and adaptation.

METHOD

Stage 1: Criteria for scientific quality and local appropriateness were developed for the selection/adaptation of an intervention to promote lifestyle change in people of high cardiovascular risk through (1) patient interviews, (2) a literature search to extract evidence-based criteria for behavioural interventions, and (3) stakeholder consultation. Stage 2: Potential interventions for adaptation were identified and ranked according to their performance against the criteria developed in Stage 1. Stage 3: Intervention mapping (IM) techniques were used to (1) specify the behavioural objectives that participants would need to reach in order to attain programme outcomes, and (2) adapt the selected intervention to ensure that evidence-based strategies to target all identified behavioural objectives were included.

RESULTS

Four of 23 potential interventions identified met the 11 essential criteria agreed by a multi-disciplinary stakeholder committee. Of these, the Greater Green Triangle programme (Laatikainen et al., 2007) was ranked highest and selected for adaptation. The IM process identified 13 additional behaviour change strategies that were used to adapt the intervention for the local context.

CONCLUSIONS

IM provided a useful set of techniques for the systematic adaptation of an existing lifestyle intervention to a new population and context, and facilitated transparent working processes for a multi-disciplinary team.

Plant science and human nutrition: challenges in assessing health-promoting properties of phytochemicals

The rise in noncommunicable chronic diseases associated with changing diet and lifestyles throughout the world is a major challenge for society. It is possible that certain dietary components within plants have roles both in reducing the incidence and progression of these diseases. We critically review the types of evidence used to support the health promoting activities of certain phytochemicals and plant-based foods and summarize the major contributions but also the limitations of epidemiological and observational studies and research with the use of cell and animal models. We stress the need for human intervention studies to provide high-quality evidence for health benefits of dietary components derived from plants.

Cardiovascular risk scores do not account for the effect of treatment: a review

Objective

To compare the strengths and limitations of cardiovascular risk scores available for clinicians in assessing the global (absolute) risk of cardiovascular disease.

Design

Review of cardiovascular risk scores.

Data sources

Medline (1966 to May 2009) using a mixture of MeSH terms and free text for the keywords ‘cardiovascular’, ‘risk prediction’ and ‘cohort studies’.

Eligibility criteria for selecting studies

A study was eligible if it fulfilled the following criteria: (1) it was a cohort study of adults in the general population with no prior history of cardiovascular disease and not restricted by a disease condition; (2) the primary objective was the development of a cardiovascular risk score/equation that predicted an individual's absolute cardiovascular risk in 5–10 years; (3) the score could be used by a clinician to calculate the risk for an individual patient.

Results

21 risk scores from 18 papers were identified from 3536 papers. Cohort size ranged from 4372 participants (SHS) to 1591209 records (QRISK2). More than half of the cardiovascular risk scores (11) were from studies with recruitment starting after 1980. Definitions and methods for measuring risk predictors and outcomes varied widely between scores. Fourteen cardiovascular risk scores reported data on prior treatment, but this was mainly limited to antihypertensive treatment. Only two studies reported prior use of lipid-lowering agents. None reported on prior use of platelet inhibitors or data on treatment drop-ins.

Conclusions

The use of risk-factor-modifying drugs—for example, statins—and disease-modifying medication—for example, platelet inhibitors—was not accounted for. In addition, none of the risk scores addressed the effect of treatment drop-ins—that is, treatment started during the study period. Ideally, a risk score should be derived from a population free from treatment. The lack of accounting for treatment effect and the wide variation in study characteristics, predictors and outcomes causes difficulties in the use of cardiovascular risk scores for clinical treatment decision.

Patient and general practitioner attitudes to taking medication to prevent cardiovascular disease after receiving detailed information on risks and benefits of treatment: a qualitative study

BACKGROUND

There are now effective drugs to prevent cardiovascular disease and guidelines recommend their use. Patients do not always choose to accept preventive medication at levels of risk reduction recommended in guidelines. The purpose of the study was to identify and explore the attitudes of patients and general practitioners towards preventative medication for cardiovascular disease (CVD) after they have received information about it; to identify implications for practice and prescribing.

METHODS

Qualitative interviews with GPs and patients following presentation of in depth information about CVD risks and the absolute effects of medication.

SETTING

GP practices in Birmingham, United Kingdom.

RESULTS

In both populations: wide variation on attitudes to preventative medication; concerns about unnecessary drug taking & side effects; preferring to consider lifestyle changes first. In patient population: whatever their attitudes to medication were, the vast majority explained that they would ultimately do what their GP recommended; there was some misunderstanding of the distinction between curative and preventative medication. A common theme was the degree of trust in their doctors' judgement and recommendations, which contrasted with scepticism of the role of pharmaceutical companies and academics. Scepticism in guidelines was also common among doctors although many nevertheless recommended treatment for their patients

CONCLUSIONS

A guideline approach to prescribing preventative medication could be against the interests and preferences of the patient. GPs must take extra care to explain what preventative medication is and why it is recommended, attempt to discern preferences and make recommendations balancing these potentially conflicting concerns.

Blood pressure, lipids and glucose in type 2 diabetes: how low should we go? Re-discovering personalized care

Epidemiological studies have clearly shown a direct relationship between the levels of blood pressure, glycaemia and LDL-cholesterol, and the complications of diabetes. Although 'lower should be better', the results of recent clinical trials examining the benefits of normalizing risk factor levels have been counter-intuitive and, at times, disturbing, and have called into question this notion. This review focuses on patients with type 2 diabetes who make up 90% of patients with diabetes. It aims to provide a clear summary and interpretation of recent trials to help clinicians to set targets for cardiovascular risk factors in individual patients. It highlights areas of agreement and disagreement between current guidelines. Recent data indicate that some patient subgroups might respond differently to aggressive risk factor management. Our challenge is how to identify these patients and deliver truly personalized diabetes care that maximizes benefit, and minimizes harm. Guidelines and position statements stress the value of setting personalized targets. We explore what this means, and how this might be achieved in practice by outlining some solutions to issues that currently limit the delivery of personalized care. We call for further research assessing the overall clinical impact of cardiovascular risk factor intervention by finding appropriate ways of combining data on mortality, complications, side-effects, quality of life, and cost-effectiveness.