Secondary prevention of coronary artery disease in high-risk diabetic patients

Association of physicians' accuracy in recording with quality of care in cardiovascular medicine

BACKGROUND

Physicians' adherence to cardiovascular (CV) guidelines has been found to be poor. In this regard, accuracy in keeping medical records could play an important role. This study was devised to describe which data are present in medical records from a large sample of physicians and to investigate the association and the link between completeness in recording and clinical appropriateness.

METHODS

The data extracted from medical records of 1078 doctors (general practitioners, cardiologists, and diabetologists) were analyzed, with a focus on CV prevention. The percentage of recorded data of several CV clinical variables was calculated. A multivariate analysis was performed to investigate the association between doctors' and patients' characteristics and different patterns in recording. Finally, the completeness in recording was calculated with a score and plotted against three indicators of appropriateness.

RESULTS

The only risk factor that achieved a good standard of registration was blood pressure (89%). Low-density lipoprotein and waist circumference were largely under-recorded, whereas lifestyle data collection was almost negligible. Age, specialization, and use of electronic records increase the accuracy in recording. When one CV risk factor was predominant, the probability of having other risk factors recorded was reduced. A significant increase in the proportion of patients treated according to guidelines was found in doctors who were more accurate in recording.

CONCLUSION

A link exists between accuracy in recording with both quality of care and adherence to guidelines. Specific training of all doctors in this field should be considered.

The clinical reality of guidelines for primary prevention of cardiovascular disease in type 2 diabetes in Italy

INTRODUCTION AND AIM

Guidelines for cardiovascular prevention in diabetes have been issued by the national and international scientific societies. No audit as ever been performed to evaluate the implementation of these documents in clinical practice in Italy. The study evaluates the prevalence, treatment, and control of major cardiovascular risk factors in type 2 diabetic patients, to assess the clinical practice of primary cardiovascular prevention in type 2 diabetes.

PATIENTS AND METHODS

Two thousand four hundred and sixty-five men and women with type 2 diabetes, aged 50-75 and free of cardiovascular events were recruited on a consecutive basis at 10 hospital based outpatients diabetes clinics. Clinical variables were measured by standard protocol. Biochemical parameters were evaluated at each centre. The laboratories were monitored by an external quality control assessment in order to reach and maintain a standard of quality and traceability among the participating centres.

RESULTS

A minority of patients (5%) met the recommended targets for LDL cholesterol, blood pressure, glycated haemoglobin and smoking habits, whereas the vast majority (66%) had unsatisfactory control of three or more of the above. Achievement of desirable control of risk factors differed according to gender and known diabetes duration. Lipid lowering and, to a lesser extent, antihypertensive medications were under-used and their titration insufficiently target-driven. Prophylactic use of antiplatelet agents was scarce, only one out of five patients was treated independent of absolute cardiovascular risk.

CONCLUSION

In clinical practice there is poor adherence to national and international guidelines for primary cardiovascular prevention in type 2 diabetes in Italy. The study underlines the great potential for prevention, particularly in women and in high-risk patients.

Incidence and risk factors for stroke in type 2 diabetic patients: the DAI study

BACKGROUND AND PURPOSE

Type 2 diabetes mellitus is a strong predictor of cerebrovascular disease, yet few studies have assessed the incidence of stroke and the role of other risk factors in unselected type 2 diabetes mellitus populations.

METHODS

We prospectively followed-up 14,432 type 2 diabetes mellitus patients, aged 40 to 97 years, with and without a history of cardiovascular disease at enrollment, and we estimated the incidence of stroke and the hazards ratios with respect to clinical variables.

RESULTS

During a 4-year follow-up, 296 incident stroke events were recorded. In persons with no history of cardiovascular disease, the age-standardized incidence of stroke (per 1000 person-years) was 5.5 (95% confidence interval, 4.2 to 6.8) in men and 6.3 (95% confidence interval, 4.5 to 8.2) in women. In persons with a history of cardiovascular disease, it was 13.7 (95% confidence interval, 7.5 to 19.8) in men and 10.8 (95% confidence interval, 7.3 to 14.4) in women. The hazards ratios of stroke incidence varied according to age, sex, and history of cardiovascular disease. Among men with no history, HbA1c and smoking were predictors of stroke. Among patients with a history, the risk factors were, in men, therapy with insulin plus oral agents, treated high total cholesterol and low HDL cholesterol, whereas in women microvascular complications were a risk factor. Previous stroke was a strong predictor of stroke in both sexes.

CONCLUSIONS

Age and previous stroke are the main predictors of stroke in diabetes. The combined role of Hba1c, microvascular complications, low HDL cholesterol, and treatment with insulin plus oral agents highlights the importance of diabetic history and clinical background in the development of stroke.

The under-use of statin in type 2 diabetic patients attending diabetic clinics in Italy

BACKGROUND AND AIMS

The greatest decrease in mortality from cardiovascular disease (CAD) that can be achieved with 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors (statins) is seen in patients with the highest risk for CAD, such as diabetics. Yet, there is evidence for inadequate use of drug therapies to achieve lipid goals. Our aims were to: (1) assess the prevalence of statin use in patients attending diabetic clinics and (2) correlate the use of statins with their risk and clinical status.

METHODS AND RESULTS

Of 9921 patients included, only 20.4% of them were receiving statin therapy. Statins were more progressively prescribed in those with risk factors additional to that of diabetes. Patients under statin treatment were older, mostly type 2 diabetics, more hypertensive and hyperlipidemic, had a higher prevalence of both macro- and microvascular disease. Among those with a total cholesterol concentration above 252 mg/dl, statin treatment was given only to 60% of diabetic patients with prior myocardial infarction, 56% of those with angina, 66% of those having had prior revascularization procedure, 54% of those with cerebrovascular disease and 51% of those with peripheral artery disease.

CONCLUSIONS

At least in Italy, statins are not prescribed to the majority of diabetic patients, and a substantial proportion of patients not treated with statins present significant macro- and microvascular complications.

Cardiovascular risk factors and metabolic control in type 2 diabetic subjects attending outpatient clinics in Italy: the SFIDA (survey of risk factors in Italian diabetic subjects by AMD) study

BACKGROUND AND AIM

To perform an observational, cross-sectional study aiming to assess multiple cardiovascular risk factors and metabolic control in a very large and representative sample of type 2 diabetic subjects attending diabetes outpatient clinics (DOCs) in Italy.

METHODS AND RESULTS

Two hundred and sixty-one clinics were involved, representing about one-third of the whole number of DOCs in the Country. Each clinic recruited on a random basis from 50 to 100 type 2 diabetic patients aged 35-70 years, diagnosed more than six months before the start of the study. Demographic and clinical data were collected and blood pressure, lipids, HbA(1c), fasting blood glucose (FBG), and microalbuminuria were measured. Overall, 12,222 type 2 diabetic patients were recruited in 253 DOCs. Female subjects showed higher FBG, HbA 1c, blood pressure, lipid levels, and a longer duration of disease. The proportion of patients with BMI > or = 30 was 33.3% among males and 45.9% among females; 40.9% of male patients had a waist circumference greater than 102 cm, while 79% of female patients had a waist circumference over 88 cm. More than two-third of the patients (74.4%) had systolic blood pressure values of > or = 130 mmHg, and one-third (33.2%) had diastolic values > or = 85 mmHg. The mean value of HbA(1c) was 7.6+/-1.6, and 23.7% of the observed population had an HbA 1c level > 8.5%. More than half of the study population had total cholesterol levels > or = 5.2 mmol/l, 47% had LDL cholesterol values of 3.3 mmol/l or greater and 9.6% had HDL cholesterol level lower than 0.90 mmol/l. The presence of multiple lipid alterations was associated with markedly higher HbA 1c levels, in both subjects treated with lipid lowering drugs and untreated subjects. Finally, even moderate increases in HbA 1c levels (i.e. HbA 1c > 7.5%) were associated with a statistically significant greater risk of systolic blood pressure levels > or = 160 mmHg in women (OR = 1.40; 95% CI 1.09-1.80) but not in men (OR = 1.21; 95% CI 0.96-1.54).

CONCLUSIONS

The SFIDA study provides a clear indication of the need to orient diabetes care towards the control of global cardiovascular risk. Only a stricter adherence to the existing guidelines and a much stronger attention to the attainment of the desired therapeutic goals will allow a decrease in morbidity and mortality as well as in the costs related to diabetes.