ABCs of secondary prevention of CHD: easier said than done

How general practitioners perceive and grade the cardiovascular risk of their patients

BACKGROUND

Although risk assessment charts have been proposed to identify patients at high cardiovascular risk, in everyday practice general practitioners (GPs) often use their knowledge of the patients to estimate the risk subjectively.

DESIGN

A cross-sectional study aimed to describe how GPs perceive, qualify and grade cardiovascular risk in everyday practice.

METHODS

General practitioners had to identify in a random sample of 10% of their contacts the first 20 consecutive patients perceived as being at cardiovascular risk. For each patient essential data were collected on clinical history, physical examination and laboratory tests, for the qualification of risk. At the end of the process GPs subjectively estimated the overall patient's level of risk. General practitioners grading was compared with the risk estimate from a reference chart.

RESULTS

Over a mean time of 25 days 3120 patients perceived as being at cardiovascular risk were enrolled. According to the inclusion scheme each GP had contact with more than 200 patients at cardiovascular risk every month. Thirty percent of these patients had atherosclerotic diseases. Up to 72% of patients without any history of atherosclerotic diseases but perceived to be at risk could be classified according to a reference chart as being at moderate to very high risk. Comparing GPs' grading of risk with a chart estimate there was agreement in 42% of the cases. Major determinants of GPs' underestimation of risk were age, sex and smoking habits, while obesity and family history were independently associated with overestimation.

CONCLUSIONS

On the basis of their perception GPs properly identify patients at cardiovascular risk in the majority of cases. General practitioners subjective grading of risk level only partially agreed with that given by a chart.

Development and validation of an English version of the Coronary Artery Disease Education Questionnaire (CADE-Q)

BACKGROUND

The Coronary Artery Disease Education Questionnaire (CADE-Q) is a validated specific tool used to assess the knowledge and educate coronary patients in cardiac rehabilitation on aspects related to coronary artery disease (CAD). The aim of this study is to translate, cross-culturally adapt and validate from Portuguese to English the Coronary Artery Disease Education Questionnaire (CADE-Q).

METHODS

Two independent translations were performed by qualified translators. After back-translation, both versions were reviewed by a committee of experts. A final English version was tested in a pilot study. For the psychometric validation, the tool was administered to 200 Canadian coronary patients enrolled in cardiac rehabilitation (CR). The internal consistency was assessed using Cronbach's alpha, the test-retest reliability using intraclass correlation coefficient (ICC), and the construct validity through factor analysis. Criterion validity of CADE-Q was assessed with regard to patients' characteristics.

RESULTS

Eleven of 19 questions were modified and culturally adapted in the English version. Cronbach's alpha was 0.809 and ICC was 0.846. Factor analysis revealed five factors, all internally consistent and well defined by the items. Criterion validity was supported by significant differences in mean scores by family income (p = 0.02) and educational level (p < 0.001).

CONCLUSION

The English version of the CADE-Q was demonstrated to have adequate reliability and validity, supporting its use in further studies.

Cardiovascular manifestations of insulin resistance

Data from the Centers for Disease Control and Prevention indicate that the prevalence of diabetes is increasing steadily and is coupled with a rise in obesity. Studies such as the Nurses' Health Study show that even slight glucose abnormalities, namely insulin resistance, increase the risk of myocardial infarctions, strokes, other cardiovascular disease, and mortality. Insulin resistance was found to accelerate atherosclerosis, inflammation, the onset of diabetes, cardiovascular disease, obesity, hypertension, chronic kidney disease, and dyslipidemia. Adiponectin was found to have potent antiinflammatory and antiatherosclerotic effects. Similarly, studies indicate that peroxisome proliferators-activated receptor agonists have the potential to treat obesity, diabetes, and atherosclerosis. From a preventive standpoint, it was shown that intensive glucose control reduces long-term cardiovascular risk. This intensive control approach included the use of thiazolidinediones (TZDs; troglitazone, pioglitazone, and rosiglitazone), which were demonstrated to have vascular and nonglycemic effects beyond glucose-lowering. A drawback of using TZDs is peripheral fluid retention. The DREAM study showed that participants with impaired fasting glucose or impaired glucose tolerance who are free from cardiovascular disease benefited significantly from taking 8 mg rosiglitazone per day. The ADOPT study provided evidence that rosiglitazone is more efficient at controlling glycemic loss and maintaining low glycosylated hemoglobin levels than metformin and glyburide. Data from the CHICAGO study indicate that the progression of carotid artery intima-media thickness, a marker of atherosclerosis and a surrogate end point for cardiovascular disease, was slowed more with pioglitazone than glimepiride in a racially diverse population of men and women with diabetes mellitus type 2. Overall, investigators have shifted from a focus on hyperglycemia to a multifactorial approach to risk management in diabetes. This multifactorial approach includes intensive glycemic control, lifestyle intervention, and intensive management of comorbid (dyslipidemia, hypertension, early renal disease) conditions. The implementation of a regular, rigorous exercise and diet program greatly decreased insulin resistance and allowed far more patients to reach their glycosylated hemoglobin goals. Studies with atrovastatin show significant improvement in cardiovascular risk factors in patients with diabetes and hypertension. Short-term studies provide support for the administration of a combination of TZD + sulfonylureas in patients with diabetes mellitus type 2. Likewise, studies have shown that a combination of TZDs + metformin reduced the risk of myocardial infarction. Finally, dipeptidyl peptidase-IV inhibitors and glycolipoprotein-1 analogs show potential for helping prevent the deterioration of glucose metabolism in early diabetes mellitus type 2.

Risk factors and in-hospital outcomes in stroke and myocardial infarction patients

BACKGROUND

Acute stroke (AS) and acute myocardial infarction (AMI) share major risk factors such as age, gender, and high blood pressure. The main objective of this study was to compare vascular risk factor profiles with in-hospital outcomes in AS and AMI patients.

METHODS

We evaluated 486 consecutive patients who were admitted to Bjelovar General Hospital with diagnoses of AS (ischaemic stroke or intracerebral haemorrhage; N = 380) or AMI (N = 106) during a one year period. The frequency of risk factors and in-patient mortality rates were assessed in both groups. For statistical analysis we used t-tests and chi2 tests.

RESULTS

AS patients were significantly older than AMI patients: the mean age for AS patients was 68.9 +/- 9.1 years, and for AMI patients was 62.8 +/- 11.7 years (p < 0.001). AMI was significantly more common than AS in patients younger than 65 years; 51% of this group had AMI and 26% had AS (p < 0.001). Hypertension was a more common risk factor in AS patients (69% AS patients vs. 58% AMI patients; p = 0.042). Patients who died did not differ significantly in age between the groups. In-patient mortality rates were significantly higher in AS than AMI cases (31% vs. 12%, p < 0.001 for all patients; 37% vs.5%, p < 0.001 for men). Women hospitalized for AMI were more likely to die in hospital than men (28% vs. 5%; p = 0.002).

CONCLUSIONS

We found that age at the time of presentation was a significant differentiating factor between patients with AS and AMI. The only exceptions were women, whose ages at the onset of AS and AMI were similar. In contrast, patients who died did not differ significantly in age. We observed significantly higher inpatient mortality for men (when adjusted for age) than for women with AS. The five-fold higher in-patient mortality rate in women than in men with AMI is most likely to have resulted from other factors related to treatment.

Is biology destiny? Is it all in our genes?

The completion of the working draft of the human genome in 2001 is an important milestone in achieving greater understanding of the role of genetics in health and disease. This very important technological achievement holds both promise and peril for the theory and practice of medicine. The author discusses how the information in the genome, coupled with insights into the interactions of gene and environment, may revolutionize clinical practice and eventually make it possible to tailor diagnosis and treatment to the allelic and experiential nature of the individual patient. He also points out the dangers of leaping from gene discovery to premature diagnosis and unproven interventions that may endanger patients and gives several examples of such occurrences. What is known about the relationship between gene and phenotype is reviewed and examples of the different phenotypes that may arise with identical genomes are presented to illustrate how environment influences gene expression, both in humans and other species. Finally, the author considers the challenge in conveying newly gained knowledge of genetic risk in ways that will benefit rather than harm patients.

Randomised trials of secondary prevention programmes in coronary heart disease: systematic review

OBJECTIVE

To determine whether multidisciplinary disease management programmes for patients with coronary heart disease improve processes of care and reduce morbidity and mortality.

DATA SOURCES

Randomised clinical trials of disease management programmes in patients with coronary heart disease were identified by searching Medline 1966-2000, Embase 1980-99, CINAHL 1982-99, SIGLE 1980-99, the Cochrane controlled trial register, the Cochrane effective practice and organisation of care study register, and bibliographies of published studies.

DATA EXTRACTION

Studies were selected and data were extracted independently by two investigators, and summary risk ratios were calculated by using both the random effects model and the fixed effects model.

DATA SYNTHESIS

A total of 12 trials (9803 patients with coronary heart disease) were identified. Disease management programmes had positive impacts on processes of care. Patients randomised to these programmes were more likely to be prescribed efficacious drugs (risk ratio 2.14 (95% confidence interval 1.92 to 2.38) for lipid lowering drugs, 1.19 (1.07 to 1.32) for beta blockers, and 1.07 (1.03 to 1.11) for antiplatelet agents). Five out of seven trials evaluating risk factor profiles showed significantly greater improvements with these programmes in comparison with usual care (with effect sizes in the moderate range). Summary risk ratios were 0.91 (0.79 to 1.04) for all cause mortality, 0.94 (0.80 to 1.10) for recurrent myocardial infarction, and 0.84 (0.76 to 0.94) for admission to hospital. Five of the eight trials evaluating quality of life or functional status reported better outcomes in the intervention arms. Only three of these trials reported the costs of the intervention-the interventions were cost saving in two cases.

CONCLUSIONS

Disease management programmes improve processes of care, reduce admissions to hospital, and enhance quality of life or functional status in patients with coronary heart disease. The programmes' impact on survival and recurrent infarctions, their cost effectiveness, and the optimal mix of components remain uncertain.