General practitioners maintain a focus on blood pressure management rather than absolute cardiovascular disease risk management

Comparison of Patients Classified as High-Risk between International Cardiovascular Disease Primary Prevention Guidelines

Background: Cardiovascular disease (CVD) primary prevention guidelines classify people at high risk and recommended for pharmacological treatment based on clinical criteria and absolute CVD risk estimation. Despite relying on similar evidence, recommendations vary between international guidelines, which may impact who is recommended to receive treatment for CVD prevention. Objective: To determine the agreement in treatment recommendations according to guidelines from Australia, England and the United States. Methods: Cross-sectional analysis of the National Health and Nutrition Examination Survey (n = 2647). Adults ≥ 40 years were classified as high-risk and recommended for treatment according to Australia, England and United States CVD prevention guidelines. Agreement in high-risk classification and recommendation for treatment was assessed by Kappa statistic. Results: Participants were middle aged, 49% were male and 38% were white. The proportion recommended for treatment was highest using the United States guidelines (n = 1318, 49.8%) followed by the English guidelines (n = 1276, 48.2%). In comparison, only 26.6% (n = 705) of participants were classified as recommended for treatment according to the Australian guidelines. There was moderate agreement in the recommendation for treatment between the English and United States guidelines (κ = 0.69 [0.64-0.74]). In comparison, agreement in recommendation for treatment was minimal between the Australian and United States guidelines (κ = 0.47 [0.43-0.52]) and weak between the Australian and English guidelines (κ = 0.50 [0.45-0.55]). Conclusions: Despite similar evidence underpinning guidelines, there is little agreement between guidelines regarding the people recommended to receive treatment for CVD prevention. These findings suggest greater consistency in high-risk classification between CVD prevention guidelines may be required.

Implementing decision aids for cardiovascular disease prevention: stakeholder interviews and case studies in Australian primary care

BACKGROUND

Australian cardiovascular disease (CVD) prevention guidelines recommend absolute CVD risk assessment, but less than half of eligible patients have the required risk factors recorded due to fragmented implementation over the last decade. Co-designed decision aids for general practitioners (GPs) and consumers have been developed that improve knowledge barriers to guideline-recommended CVD risk assessment and management. This study used a stakeholder consultation process to identify and pilot test the feasibility of implementation strategies for these decision aids in Australian primary care.

METHODS

This mixed methods study included: (1) stakeholder consultation to map existing implementation strategies (2018-20); (2) interviews with 29 Primary Health Network (PHN) staff from all Australian states and territories to identify new implementation opportunities (2021); (3) pilot testing the feasibility of low, medium, and high resource implementation strategies (2019-21). Framework Analysis was used for qualitative data and Google analytics provided decision support usage data over time.

RESULTS

Informal stakeholder discussions indicated a need to partner with existing programs delivered by the Heart Foundation and PHNs. PHN interviews identified the importance of linking decision aids with GP education resources, quality improvement activities, and consumer-focused prevention programs. Participants highlighted the importance of integration with general practice processes, such as business models, workflows, medical records and clinical audit software. Specific implementation strategies were identified as feasible to pilot during COVID-19: (1) low resource: adding website links to local health area guidelines for clinicians and a Heart Foundation toolkit for primary care providers; (2) medium resource: presenting at GP education conferences and integrating the resources into audit and feedback reports; (3) high resource: auto-populate the risk assessment and decision aids from patient records via clinical audit software.

CONCLUSIONS

This research identified a wide range of feasible strategies to implement decision aids for CVD risk assessment and management. The findings will inform the translation of new CVD guidelines in primary care. Future research will use economic evaluation to explore the added value of higher versus lower resource implementation strategies.

Pathogenic bacteria and treatment resistance in older cardiovascular disease patients with lung infection and risk prediction model

This study analyzes the distribution of pathogenic bacteria and their antimicrobial susceptibilities in elderly patients with cardiovascular diseases to identify risk factors for pulmonary infections. A risk prediction model is established, aiming to serve as a clinical tool for early prevention and management of pulmonary infections in this vulnerable population. A total of 600 patients were categorized into infected and uninfected groups. Independent risk factors such as older age, diabetes history, hypoproteinemia, invasive procedures, high cardiac function grade, and a hospital stay of ≥10 days were identified through logistic regression. A predictive model was constructed, with a Hosmer-Lemeshow goodness of fit (P = 0.236) and an area under the receiver operating characteristic curve of 0.795, demonstrating good discriminative ability. The model had 63.40% sensitivity and 82.80% specificity, with a cut-off value of 0.13. Our findings indicate that the risk score model is valid for identifying high-risk groups for pulmonary infection among elderly cardiovascular patients. The study contributes to the early prevention and control of pulmonary infections, potentially reducing infection rates in this vulnerable population.

Absolute cardiovascular risk assessment by Australian early-career general practitioners: a cross-sectional study

OBJECTIVE

To determine the prevalence and associations of general practice registrars' performing absolute cardio-vascular risk (ACVR) assessment (ACVRa).

DESIGN

A cross-sectional study employing data (2017-2018) from the Registrar Clinical Encounters in Training project, an ongoing inception cohort study of Australian GP registrars. The outcome measure was whether an ACVRa was performed. Analyses employed univariable and multivariable regression. Analysis was conducted for all patient problems/diagnoses, then for an 'at-risk' population (specific problems/diagnoses for which ACVRa is indicated).

SETTING

Three GP regional training organisations (RTOs) across three Australian states.

PARTICIPANTS

GP registrars training within participating RTOs.

RESULTS

1003 registrars (response rate 96.8%) recorded details of 69 105 problems either with Aboriginal and/or Torres Strait patients aged 35 years and older or with non-Indigenous patients aged 45 years and older. Of these problems/diagnoses, 1721 (2.5% (95% CI 2.4% to 2.6%)) involved an ACVRa. An ACVRa was 'plausibly indicated' in 10 384 problems/diagnoses. Of these, 1228 (11.8% (95% CI 11.2% to 12.4%)) involved ACVRa. For 'all problems/diagnoses', on multivariable analysis female gender was associated with reduced odds of ACVRa (OR 0.61 (95% CI 0.54 to 0.68)). There was some evidence for Aboriginal and/or Torres Strait Islander people being more likely to receive ACVRa (OR 1.40 (95% CI 0.94 to 2.08), p=0.10). There were associations with variables related to continuity of care, with reduced odds of ACVRa: if the patient was new to the registrar (OR 0.65 (95% CI 0.57 to 0.75)), new to the practice (OR 0.24 (95% CI 0.15 to 0.38)) or the problem was new (OR 0.68 (95% CI 0.59 to 0.78)); and increased odds if personal follow-up was organised (OR 1.43 (95% CI 1.24 to 1.66)). For 'ACVRa indicated' problems/diagnoses, findings were similar to those for 'all problems/diagnoses'. Association with Aboriginal and/or Torres Strait Islander status, however, was significant at p<0.05 (OR 1.60 (95% CI 1.04 to 2.46)) and association with female gender was attenuated (OR 0.88 (95% CI 0.77 to 1.01)).

CONCLUSION

Continuity of care is associated with registrars assessing ACVR, reinforcing the importance of care continuity in general practice. Registrars' assessment of an individual patient's ACVR is targeted to patients with individual risk factors, but this may entail ACVRa underutilisation in female patients and younger age groups.

Predicted cardiovascular disease risk and prescribing of antihypertensive therapy among patients with hypertension in Australia using MedicineInsight

Hypertension guidelines recommend that absolute cardiovascular disease (CVD) risk guide the management of hypertensive patients. This study aimed to assess the proportion of patients with diagnosed hypertension with sufficient data to calculate absolute CVD risk and determine whether CVD risk is associated with prescribing of antihypertensive therapies. This was a cross-sectional study using a large national database of electronic medical records of patients attending general practice in 2018 (MedicineInsight). Of 571,492 patients aged 45-74 years without a history of CVD, 251,733 [40.6% (95% CI: 39.8-41.2)] had a recorded hypertension diagnosis. The proportion of patients with sufficient recorded data available to calculate CVD risk was higher for patients diagnosed with hypertension [51.0% (95% CI: 48.0-53.9)] than for patients without a diagnosis of hypertension [38.7% (95% CI: 36.5-41.0)]. Of those patients with sufficient data to calculate CVD risk, 29.3% (95% CI: 28.1-30.6) were at high risk clinically, 6.0% (95% CI: 5.8-6.3) were at high risk based on their CVD risk score, 12.8% (95% CI: 12.5-13.2) at moderate risk and 51.8% (95% CI: 50.8-52.9) at low risk. The overall prevalence of antihypertensive therapy was 60.9% (95% CI: 59.3-62.5). Prescribing was slightly lower in patients at high risk based on their CVD risk score [57.4% (95% CI: 55.4-59.4)] compared with those at low [63.3% (95% CI: 61.9-64.8)] or moderate risk [61.8% (95% CI: 60.2-63.4)] or at high risk clinically [64.1% (95% CI: 61.9-66.3)]. Guideline adherence is suboptimal, and many patients miss out on treatments that may prevent future CVD events.

Histone Methylation Related Therapeutic Challenge in Cardiovascular Diseases

The epidemic of cardiovascular diseases (CVDs) is predicted to spread rapidly in advanced countries accompanied by the high prevalence of risk factors. In terms of pathogenesis, the pathophysiology of CVDs is featured by multiple disorders, including vascular inflammation accompanied by simultaneously perturbed pathways, such as cell death and acute/chronic inflammatory reactions. Epigenetic alteration is involved in the regulation of genome stabilization and cellular homeostasis. The association between CVD progression and histone modifications is widely known. Among the histone modifications, histone methylation is a reversible process involved in the development and homeostasis of the cardiovascular system. Abnormal methylation can promote CVD progression. This review discusses histone methylation and the enzymes involved in the cardiovascular system and determine the effects of histone methyltransferases and demethylases on the pathogenesis of CVDs. We will further demonstrate key proteins mediated by histone methylation in blood vessels and review histone methylation-mediated cardiomyocytes and cellular functions and pathways in CVDs. Finally, we will summarize the role of inhibitors of histone methylation and demethylation in CVDs and analyze their therapeutic potential, based on previous studies.