Use of secondary prevention pharmacotherapy after first myocardial infarction in patients with diabetes mellitus

Gender disparity in the prescription of secondary prevention medications in a Malaysian primary care clinic

INTRODUCTION

Cardiovascular disease is the leading cause of death worldwide. Despite the proven benefit of secondary prevention medications (SPMs), their utilisation remains suboptimal in many countries. This study aimed to assess the use of SPMs in a Malaysian primary care clinic and factors associated with it.

METHODS

A retrospective review of electronic medical records was conducted to assess the prescription of SPMs among patients with coronary artery disease who attended the clinic between 1st January 2018 and 31st December 2018. Prescriptions of SPMs were documented in numbers and percentages. Multiple logistic regressions were used to analyse factors associated with the prescription of SPMs.

RESULTS

Of the 662 patients included in the study, 99.1% were prescribed statins, 97% antiplatelets, 81.7% angiotensin-converting enzyme (ACE)-inhibitors or angiotensin II receptor blockers (ARBs), and 78.7% beta-blockers. Male patients were more likely to be prescribed statins (OR = 8.584, 95% CI: 1.431 - 51.510) and antiplatelets (OR = 6.818, 95% CI: 2.294 - 20.257). Another significant factor for antiplatelets prescription was having diabetes (OR = 3.318, 95% CI: 1.148 - 9.590). Having hypertension was associated with ACE-inhibitors or ARBs prescription (OR = 4.008, 95% CI: 2.522 - 6.370).

CONCLUSION

Although the majority of patients received SPMs, there were significant disparities for some SPMs prescriptions among female patients. As these medications are widely available in the Malaysian primary care setting, steps should be taken to ensure that these medications are prescribed equally for all eligible patients.

Outcomes in CME/CPD - Special Collection: How to make the "pyramid" a perpetuum mobile

Continuing medical education (CME) should not be an end in itself, but as expressed in Moore's pyramid, help to improve both individual patient and ultimately community, health. However, there are numerous barriers to translation of physician competence into improvements in community health. To enhance the effect CME may achieve in improving community health the authors suggest a kick-off/keep-on continuum of medical competence, and integration of aspects of public health at all levels from planning to delivery and outcomes measurement in CME.

Sudden cardiac death among persons with diabetes aged 1-49 years: a 10-year nationwide study of 14 294 deaths in Denmark

AIMS

The aim of this study was to compare nationwide incidence rate (IR) of sudden cardiac death (SCD) in persons aged 1-49 years with and without diabetes mellitus (DM).

METHODS AND RESULTS

The study population consisted of all persons in Denmark aged 1-49 years in 2000-09, which equals 27.1 million person-years. All 14 294 deaths in the 10-year period were included. By using the highly descriptive Danish death certificates, 1698 cases of sudden and unexpected death were identified. Through review of autopsy reports, discharge summaries, and the Danish registries, we identified 1363 cases of SCD. The Danish Register of Medicinal Product Statistics was used to identify persons with type 1 DM and type 2 DM. Among the 14 294 decedents, there were 669 with DM, of which 118 suffered SCD (9% of all SCD), making SCD the leading cause of death among young persons with DM. Among those aged 1-35 years, the IR of SCD-DM was 21.9 per 100 000 person-years compared to 2.6 per 100 000 person-years among persons without DM [IR ratio 8.6, 95% confidence interval (CI) 5.8-28.6]. Within the age range 36-49 years, the IR among persons with DM was 119.8 per 100 000 person-years compared to 19.7 per 100 000 person-years among persons without DM (IR ratio 6.1, 95% CI 4.7-7.8).

CONCLUSION

We found that young persons with DM aged 1-35 years had >8-fold higher SCD IR compared to young persons without DM. Our study highlights the need for early cardiovascular risk monitoring and assessment in young persons with DM.

The Antioxidant Role of Soy and Soy Foods in Human Health

Oxidative stress seems to play a role in many chronic diseases, such as cardiovascular diseases, diabetes, and some cancers. Research is always looking for effective approaches in the prevention and treatment of these pathologies with safe strategies. Given the central role of nutrition, the identification of beneficial healthy foods can be the best key to having a safe and at the same time effective approach. Soy has always aroused great scientific interest but often this attention is galvanized by the interaction with estrogen receptors and related consequences on health. However, soy, soy foods, and soy bioactive substances seem to have antioxidant properties, suggesting their role in quenching reactive oxygen species, although it was frequently mentioned but not studied in depth. The purpose of this review is to summarize the scientific evidence of the antioxidant properties of soy by identifying the human clinical trials available in the literature. A total of 58 manuscripts were individuated through the literature search for the final synthesis. Soy bioactive substances involved in redox processes appear to be multiple and their use seems promising. Other larger clinical trials with adequate standardization and adequate choice of biomarkers will fill the gap currently existing on the suggestive role of soy in antioxidant mechanisms.

Cause-specific mortality in children and young adults with diabetes mellitus: A Danish nationwide cohort study

Aims

Persons with diabetes mellitus have increased all-cause mortality compared with the general population. Nationwide studies on causes of death and mortality among young persons with diabetes mellitus are sparse. The aim of this study was to examine all-cause and cause-specific mortality in children and young adults with and without diabetes.

Methods and results

The study population consisted of all persons in Denmark aged 1–35 years in 2000–2009 and 36–49 years in 2007–2009, which equals 27.1 million person-years. All 14,294 deaths in the 10-year period were included and cause of death was established based on information from autopsy reports and death certificates. The Danish Register of Medicinal Product Statistics was used to identify persons with type 1 diabetes and type 2 diabetes. During the study period, which included 153,070 diabetic person-years, 669 (5% of all deceased) persons with diabetes mellitus died, of which 70% had type 1 and 30% had type 2 diabetes. Persons with diabetes mellitus had an all-cause mortality rate (ASMR) of 327 per 100,000 person-years compared with 74 per 100,000 person-years among persons without diabetes mellitus (ASMR ratio 4, p < 0.001). The leading cause of death among persons with diabetes mellitus was cardiac diseases (n = 230, 34%) with an ASMR ratio of 8 (95% confidence interval 6–9).

Conclusions

Young persons with diabetes mellitus had four-fold increased all-cause mortality and eight-fold increased cardiovascular mortality compared with persons without diabetes mellitus. Focus on cardiovascular risk monitoring and management among young persons with diabetes mellitus is warranted to prevent premature death in diabetes mellitus.

Substitution of red meat with soybean but not non- soy legumes improves inflammation in patients with type 2 diabetes; a randomized clinical trial

BACKGROUND AND AIMS

Several studies have documented that consumption of legumes including soybean is inversely associated with systemic inflammation and oxidative stress. This study was done to assess the effects of soy beans or non-soy legumes consumption on C-reactive protein (CRP) and malondialdehyde (MDA) among Patients with Type 2 Diabetes (T2D).

METHODS

75 persons with T2D participated in this randomized controlled clinical trial. Participants were randomized to one of the following 3 groups for 8 weeks: soy bean group (taking a cup of cooked soy beans three days a week), legumes group (taking a cup of cooked non-soy legumes three days a week) and control group (taking two servings of red meat three days a week). Anthropometric indices, dietary intakes, and serum MDA and CRP were measured at baseline and after intervention.

RESULTS

A Significant decrease was observed in serum CRP of soy bean group (P = 0.01) which was significantly more than the controls (p = 0.001), while no significant changes of CRP was observed in legume group. Serum MDA changed significantly in none of the 3 groups.

CONCLUSIONS

In conclusion, we found that substitution of red meat with soybean but not non- soy legumes may reduce inflammatory factors with no effects on oxidative stress in diabetic patients.

Time trends in statin use and incidence of recurrent cardiovascular events in secondary prevention between 1999 and 2013: a registry-based study

Background

The current study evaluated time trends of statin use and incidence of recurrent CVD in secondary prevention from 1999 to 2013 and investigated which factors were associated with statin use in secondary prevention.

Methods

Intego is a primary care registration network with 111 general practitioners working in 48 practices in Flanders, Belgium. This retrospective registry-based study included patients aged 50 years or older with a history of CVD. The time trends of statin use and incidence of recurrent CVD in secondary prevention were determined by using a joinpoint regression analysis. Multivariable mixed-effect logistic regression analysis was used to assess factors associated with statin use in patients in secondary prevention in 2013.

Results

The overall prevalence of statin use increased and showed two trends: a sharp increase from 1999 to 2005 (annual percentage change (APC) 25.4%) and a weaker increase from 2005 to 2013 (APC 3.7%). The average increase in statin use was the highest in patients aged 80 and older. Patients aged 70–79 years received the most statins. Men used more statins than women did, but both genders showed similar time trends. The incidence of CVD decreased by an average APC of 3.9%. There were no differences between men and women and between different age groups. A significant decrease was only observed in older patients without statins prescribed. In 2013, 61% of the patients in secondary prevention did not receive a statin. The absence of other secondary preventive medication was strongly associated with less statin use. Gender, age and comorbidity were associated with statin use to a lesser degree.

Conclusions

The prevalence of statin use in secondary prevention increased strongly from 1999 to 2013. Less than 50% of patients with a history of CVD received a statin in 2013. Especially patients who did not receive other secondary preventive medication were more likely to not receive a statin. Despite the strong increase in statin use, there was only a small decrease in the incidence of recurrent CVD, and this occurred mainly in older patients without statins prescribed.

Coronary artery disease severity and long-term cardiovascular risk in patients with myocardial infarction: a Danish nationwide register-based cohort study

Aim

Long-term prognostic impact of coronary artery disease (CAD) severity in stable post-myocardial infarction (MI) patients is not well known. We examined the impact of CAD severity and co-morbidity on the long-term (1 year and beyond) risk of cardiovascular events post-MI.

Methods and results

From nationwide administrative and clinical registers, we identified 55 747 MI patients, during 2004-2010, who had not experienced subsequent MI, stroke, or death within 7 days post-discharge. The risk for primary composite endpoint (MI, stroke, or cardiovascular death) was estimated for the first 365 days after MI (index MI) and from day 366 to study completion (stable post-MI population), corresponding to a mean follow-up of 3.6 (2.2) years. Risk was assessed using cumulative incidence, multivariable adjusted logistic regression and Cox proportional-hazards models. The 1-year cumulative incidence for primary endpoint was 20.0% [95% confidence interval (CI), (19.6-20.3)]. Correspondingly, the 4-year cumulative incidence for primary endpoint was 21.0% (95% CI, 20.6-21.4) in patients without events on the first year. In multivariable models with no significant stenosis as reference, CAD severity was the most important risk factor for cardiovascular events the first 365 days [left main stenosis (LMS): odds ratio and 95% CI, 4.37, 3.69-5.17; 3-vessel disease (VD), 4.18, 3.66-4.77; 2-VD, 3.23, 2.81-3.72; 1-VD, 2.12,-1.85-2.43] and remained from day 366 to study completion [LMS: hazard ratio and 95% CI, 1.91, 1.64-2.22; 3-VD, 1.85,1.65-2.07; 2-VD, 1.55, 1.38-1.74; 1-VD, 1.30, 1.16-1.45].

Conclusion

Despite contemporary treatment at baseline, stable post-MI patients' 4-year outcome was similar to 1-year outcome after MI, and CAD severity remained a critical risk factor the first year and thereafter.

Oleanolic acid protects against diabetic cardiomyopathy via modulation of the nuclear factor erythroid 2 and insulin signaling pathways

Oleanolic acid (OL) is a pentacyclic triterpene compound used for the treatment of hepatitis, liver fibrosis and liver cirrhosis. In China, there is no published research on the effect or biological utilization of OL on liver diseases. The aim of the present study was to investigate the protective effects of OL against diabetic cardiomyopathy and its possible mechanism. A rat model of diabetes was established using streptozotocin and the effect of OL on diabetic cardiomyopathy (DCM) was evaluated. The results demonstrated that OL significantly reversed the DCM-induced changes to body weight, heart rate, echocardiography and hemodynamics, phosphorylated-glycogen synthase (GS) and glycogen phosphorylase (GP) activity in diabetic rats (all P<0.01). Treatment of diabetic rats with OL significantly inhibited oxidative stress and activated heme oxygenase (HO)-1/nuclear factor erythroid 2 (Nrf2) signaling in a rat model of diabetes (both P<0.01). The results of the present study indicate that OL protects against DCM through the HO-1/Nrf2 and insulin modulating GS/GP signaling pathways.

Determinants of angiotensin-converting enzyme inhibitor (ACEI) intolerance and angioedema in the UK Clinical Practice Research Datalink

AIM

The aim of the present study was to describe the occurrence and determinants of angiotensin-converting enzyme (ACE) inhibitor (ACEI) intolerance and angioedema (AE) among patients initiating ACEI therapy in a real-world primary care population.

METHODS

Two nested case-control studies were conducted in a cohort of 276 977 patients aged ≥45 years initiating ACEIs from 2007 to 2014 in the UK Clinical Practice Research Datalink (CPRD). Cases of AE occurring for the first time during ACEI therapy (n = 416) were matched with AE-free controls (n = 4335) on the duration of ACEI treatment. Documented switches to angiotensin-II receptor blockers in the prescription records were used to identify ACEI-intolerance cases (n = 24 709), and these were matched with continuous ACEI users (n = 84 238) on the duration of ACEI therapy. Conditional logistic regression was used to assess the associations of demographic factors, comorbidities and comedication with AE and ACEI intolerance.

RESULTS

AE during ACEI therapy was associated with age over 65 years [odds ratio (OR) 1.36, 95% confidence interval (CI) 1.07, 1.73], history of allergy (OR 1.53, 95% CI 1.19, 1.96), use of calcium channel blockers (OR 1.57, 95% CI 1.23; 2.01), use of antihistamines (OR 21.25, 95% CI 16.44, 27.46) and use of systemic corticosteroids (OR 4.52, 95% CI 3.26, 6.27). ACEI intolerance was significantly associated with more comorbidities and comedication compared with AE, including allergy (OR 2.02, 95% CI 1.96, 2.09), use of antiasthmatic drugs (OR 1.51, 95% CI 1.42, 1.61) and use of antihistamines (OR 1.53, 95% CI 1.43, 1.63).

CONCLUSIONS

Among ACEI users developing AE or ACEI intolerance, several comorbidities and comedication classes were significantly more prevalent compared with ACEI users not developing these adverse reactions.

Differences in the Cardiometabolic Control in Type 2 Diabetes according to Gender and the Presence of Cardiovascular Disease: Results from the eControl Study

The objective of this cross-sectional study was to assess differences in the control and treatment of modifiable cardiovascular risk factors (CVRF: HbA1c, blood pressure [BP], LDL-cholesterol, body mass index, and smoking habit) according to gender and the presence of cardiovascular disease (CVD) in patients with type 2 diabetes mellitus (T2DM) in Catalonia, Spain. The study included available data from electronic medical records for a total of 286,791 patients. After controlling for sex, age, diabetes duration, and treatment received, both men and women with prior CVD had worse cardiometabolic control than patients without previous CVD; women with prior CVD had worse overall control of CVRFs than men except for smoking; and women without prior CVD were only better than men at controlling smoking and BP, with no significant differences in glycemic control. Finally, although the proportion of women treated with lipid-lowering medications was similar to (with prior CVD) or even higher (without CVD) than men, LDL-cholesterol levels were remarkably uncontrolled in both women with and women without CVD. The results stress the need to implement measures to better prevent and treat CVRF in the subgroup of diabetic women, specifically with more intensive statin treatment in those with CVD.