[Cholesterolemia control in Spain, 2000: a tool for cardiovascular disease prevention]

[Clinical factors associated with inappropriate prescription of statins]

BACKGROUND AND OBJECTIVE

The aim of this study was to determine the percentage of subjects receiving statin treatment that was inappropriate and to evaluate the associated clinical factors.

PATIENTS AND METHOD

A cross-sectional multi-centred study conducted across the Autonomous Regions of Spain. The appropriateness of prescription was based on the guidelines of the National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATP III) and the European Guidelines on Cardiovascular Disease Prevention.

RESULTS

Of the 1,817 patients studied, 52.9% were male, the overall mean age was 59.4 years, 36% had cardiovascular disease and 32.7% had diabetes. In 90.8% of the population the prescription was correct according to at least one of the two guides being used, with a low concordance between them (kappa = 0.279). Almost 100% of subjects with cardiovascular disease or diabetes had an appropriate prescription. In primary prevention, 82.7% had an appropriate prescription according to at least one of the two guides used, but this percentage decreased to 20.7% when based on the European Guidelines. In multivariate analysis, there was agreement with both guides. The inappropriate prescription was directly, and significantly, associated with primary prevention and female gender, while being inversely related to age, smoking habit and LDL-cholesterol concentration.

CONCLUSIONS

Most of the patients receiving statin treatment have an appropriate prescription, but the percentage of inappropriate prescription increases significantly in patients in primary prevention following European Guidelines.

[High cardiovascular risk due to inadequate control of risk factors in Spanish hypertensive patients seen in the Spanish primary care]

INTRODUCTION

Cardiovascular diseases are the main cause of morbidity-mortality in Spain. Hypertension and the other cardiovascular factors are important in the pathophysiological basis of this fact. Control of the main risk factors in treated hypertensives was evaluated in this study.

PATIENTS AND METHODS

Multicenter study in hypertensive patients treated in Primary Care. Blood pressure, cardiovascular risk factors as well as registered target organ damage and clinical diseases were measured. Finally, global cardiovascular risk was calculated.

RESULTS

Only 17.3% of pharmacologically treated hypertensives were controlled (3.9% of diabetic patients). LDL-cholesterol control deteriorated as the patient's cardiovascular risk pattern increased (90.4% in low risk and 19.9% in high-very high risk). High levels of serum creatinine were detected in 8.3%, microalbuminuria being positive in 15.6%, with 20.8% ventricular hypertrophy. A total of 31% of the patients were diabetic, 59.8% of them having HbA1c > or = 6.5%. Global CV risk was high very high in many subjects (65.4%) when European Society of Hypertension-European Society of Cardiology (ESH-ESC) guidelines were used. This percentage was 3.6% when the Spanish-validated Framingham score was used.

CONCLUSIONS

Blood pressure control as well as main cardiovascular risk factors is poor in this population. Considering this fact plus the number of target organ damage, the global risk is high in many patients according to the European guidelines. Guidelines that do not consider target organ damage do not estimate adequately the risk of this uncontrolled population. This conclusion could explain the clinical tendency of many doctors when attending uncontrolled patients.

[Lipid lowering goals in high risk and very high cardiovascular risk patients: a reasonable challenge?]

OBJECTIVE

The last modifications of the National Cholesterol Education Program (NCEP) indicate some lower therapeutic targets of low density protein cholesterol (LDL-c) in patients with very high vascular risk. Our study aims to establish the degree of compliance of the therapeutic targets defined by these modifications.

PATIENTS AND METHOD

Descriptive and cross sectional study of patients from a cardiovascular clinic. Low-density lipoprotein cholesterol (LDL-c) was calculated and targets were established according the new update of NCEP-ATP III.

RESULTS

836 patients, 625 (75%) with HR and 211(25%) with VHR were studied 45% of HR and 67% of VHR were receiving treatment with statins (p < 0.001) but only 38% of HR and 15% of VHR achieved target LDL-c levels. The percentage of patients who could achieve LDL-goals using the maximum approved dose of the statins plus other lipid lowering drug was calculated: The 31% of HR and 51% of VHR were unable to achieve the LDL-c targets.

CONCLUSIONS

Only 15% of very high risk patients achieve target levels of LDL-c according to the new NCEP-ATP III recommendations. Even using maximum dose of statins in combination with other lipid lowering drugs, less than half of the patients will be able to achieve LDL-c goal (< 70 mg/dl).

Percentiles de riesgo: un nuevo método adaptado para la valoración del riesgo vascular. Estudio ERVPA

BACKGROUND AND OBJECTIVE

Various cardiovascular scoring systems estimating the risk in the Spanish population are currently used. The aim of our study was to create graphs and charts of populational percentiles to assess the total burden of risk of a population and to place each subject individually in the context of their own population setting by using cardiovascular risk charts.

SUBJECTS AND METHOD

A cross-sectional study of 514 individuals of both sexes from a general population setting was carried out. Cardiovascular risk was calculated according to the SCORE project equations and charts and graphs of cardiovascular risk were formulated.

RESULTS

In primary prevention, 17.11% of men and 22.36% of women aged 20-79 showed a high cardiovascular risk. The percentages vary from 0% in persons of both sexes aged 20-39 to 91.2% of men and 97.9% of women in their 70s. Risk medians range in men from 0.11% (age 20-39) to 8.86% (age 70-79) and in women from 0.02% (age 20-39) to 15.20% (age 70-79). Graphs of cardiovascular risk percentiles were formulated for both sexes; graphs can be used to situate each subject individually in the context of their own population setting and to project the risk to any age.

CONCLUSIONS

Nearly a fifth of the population has a high cardiovascular risk. More than 90% of men and women in their 70s have a high cardiovascular risk.

[Variation in the prevention of cardiovascular risk factors. A population-based study]

BACKGROUND

Published studies on clinical practice variability have mainly focussed on variability in the rates of hospitalization and surgical procedures. The objective of this study was to evaluate variability in the measurement of cholesterolemia and blood pressure in four professional groups and in the general population.

METHODS

A cross-sectional survey was performed by mail in the city of Valencia (Spain). Five population groups were selected: physicians, nurses, lawyers, architects and the general population. The sample was obtained by random sampling of each group.

RESULTS

Of all the questionnaires returned, only those returned by individuals surveyed (1,755) and their partners (1,296) were used (total: 3,050). The frequency of preventive cholesterolemia measurement was greater among nurses (55.7%) and physicians (54.1%) than among architects (38.9%), lawyers (38.2%) and the general population (35.1%). The frequency of preventive blood pressure measurement was also greater among physicians (47.7%) and nurses (42.2%) followed by architects (39.4%) and lawyers (38.8%) and was lower among the general population (32.2%). After adjusting by sex, age group, marital status, level of education, and employment, only lawyers (RR = 0.79; 95% CI, 0.6-0.9) and architects (RR = 0.77; 95% CI, 0.68-0.88) showed a significantly lower probability of determining cholesterol levels than physicians (basal category) and nurses (RR = 1.05; 95% CI, 0.93-1.18). The general population showed the lowest probability of measuring blood pressure (RR = 0.8; 95% CI, 0.65-0.97), although the differences were statistically significant only when compared with physicians.

CONCLUSIONS

Preventive practices should be increased among groups in which they are less frequently performed until they are performed with the same frequency as among physicians and nurses. Efforts should be directed to increasing cardiovascular prevention programs in health centers.

Uso clínico de las estatinas y objetivos terapéuticos en relación con el riesgo cardiovascular

BACKGROUND AND OBJECTIVE

Our goal was to determine the number of patients who achieve low-density lipoprotein cholesterol (LDL-c) targets according to new guidelines.

PATIENTS AND METHOD

Descriptive and transversal study of patients from a cardiovascular clinic. LDL-c was calculated and targets were established according the NCEP-ATP III.

RESULTS

1,811 patients (46% males, 54% females) were studied. 35% of these were high-risk patients (group 1: coronary risk > 20% at 10 years), 19% were intermediate-risk patients (group 2: coronary risk 10-20% at 10 years) and 46% were low-risk patients (group 3: coronary risk < 10% at 10 years). Overall, 58% of patients achieved target LDL-c levels, yet success rates were 26% among group 1 patients, 51% among group 2 patients, and 86% among group 3 patients (p = 0.001, for differences between groups). Statin treatment was significantly related to achieving target LDL-c levels in group 1 patients (OR = 1.7; 95% CI, 1.2-2.4; p = 0.007). In group 1.41% of patients had LDL-c levels > 130 mg/dl without receiving lipid-lowering drugs.

CONCLUSIONS

Although an overall 58% patients achieve target LDL-C levels, only one of four high-risk patients have LDL-c levels < 100 mg/dl, and statin treatment is a determining factor to achieve this goal. These findings indicate that a more aggressive treatment with statins is needed in secondary prevention.

[Low-level agreement between qualitative and quantitative criteria (NCEP-II) proposed by the Ministry of Health for the lipid-lowering drug therapy in persons without coronary artery disease]

BACKGROUND

To evaluate the impact in Catalonia and the agreement between the qualitative (NCEP-II) and quantitative criteria proposed by the Health Ministry for the lipid-lowering drug therapy among individuais without coronary artery disease.

METHODS

Both qualitative (NCEP-II) and quantitative methods were used in individuals without coronary artery disease studied in a random sample of adult populations in Catalonia (n = 304) aged >/= 16 years. Patients with a LDL-cholesterol levels >/= l90 mg/dl or 160-189 mg/dl plus at least two risk factors fulfilled the qualitative criteria for the lipid-lowering drug therapy; patients with a risk >/= 20% in 10 years fulfilled the quantitative criteria. The agreement between both qualitative and quantitative criteria was evaluated by means of the Kappa index.

RESULTS

20% of males and 20.1% of females, and 24% of males and 33.1% of females fulfilled the qualitative and quantitative criteria for lipid-lowering drug therapy, respectively. A low (Kappa = 0.30) and a moderate (Kappa = 0.44) agreement was observed among males and females, respectively, regarding qualitative and quantitative criteria. Increased serum cholesterol was the determinant risk factor for fulfilling qualitative criteria (ORadj) y whereas age, increased blood pressure and increased serum cholesterol were determinants for fulfilling the quantitative criteria.

CONCLUSION

The results obtained in this study showed a low agreement between qualitative and quantitative criteria proposed by the report of the Ministry of Health Report to lower cholesterol levels by means of drug therapy among healthy people. Clear and unequivocal criteria to decide what persons are candidates for cholesterol-lowering drug therapy should be developed.

[Variation over two years of cardiovascular risk in patients cared for at primary care services for hypertension, diabetes and dyslipidemia]

OBJECTIVE

To analyse the modifications in cardiovascular risk in patients seen over two years in adult services for dyslipaemia, diabetes mellitus or hypertension.

DESIGN

Observational, retrospective study with repeated measurement tests.

SETTING

Two health centres.

PATIENTS

265 patients attended by the above services who were free of cardiovascular disease at the start of the study.

MEASUREMENTS AND RESULTS

During the study period, the cumulative incidence of cardiovascular morbidity was 4.2% (1.8-6.6%). Patients, without events, underwent a mean reduction in overall cardiovascular risk of -1.6% (p < 0.001). In patients classified as high-risk at the start of the study, the mean reduction was much greater: -3.7% (p < 0.001). Giving up smoking and controlling dyslipaemia brought about the greatest reductions in cardiovascular risk.

CONCLUSIONS

Monitoring of cardiovascular risk in patients attended for conditions in the INSALUD portfolio of services, i.e. hypertension, dyslipaemia, diabetes mellitus, enables this risk to be reduced and priority to be given to health care delivery to more vulnerable groups.