Low use of statins and other coronary secondary prevention therapies in primary and secondary care in India

Challenges in management and prevention of ischemic heart disease in low socioeconomic status people in LLMICs

BACKGROUND

Cardiovascular diseases, principally ischemic heart disease (IHD), are the most important cause of death and disability in the majority of low- and lower-middle-income countries (LLMICs). In these countries, IHD mortality rates are significantly greater in individuals of a low socioeconomic status (SES).

MAIN TEXT

Three important focus areas for decreasing IHD mortality among those of low SES in LLMICs are (1) acute coronary care; (2) cardiac rehabilitation and secondary prevention; and (3) primary prevention. Greater mortality in low SES patients with acute coronary syndrome is due to lack of awareness of symptoms in patients and primary care physicians, delay in reaching healthcare facilities, non-availability of thrombolysis and coronary revascularization, and the non-affordability of expensive medicines (statins, dual anti-platelets, renin-angiotensin system blockers). Facilities for rapid diagnosis and accessible and affordable long-term care at secondary and tertiary care hospitals for IHD care are needed. A strong focus on the social determinants of health (low education, poverty, working and living conditions), greater healthcare financing, and efficient primary care is required. The quality of primary prevention needs to be improved with initiatives to eliminate tobacco and trans-fats and to reduce the consumption of alcohol, refined carbohydrates, and salt along with the promotion of healthy foods and physical activity. Efficient primary care with a focus on management of blood pressure, lipids and diabetes is needed. Task sharing with community health workers, electronic decision support systems, and use of fixed-dose combinations of blood pressure-lowering drugs and statins can substantially reduce risk factors and potentially lead to large reductions in IHD. Finally, training of physicians, nurses, and health workers in IHD prevention should be strengthened.

CONCLUSION

The management and prevention of IHD in individuals with a low SES in LLMICs are poor. Greater availability, access, and affordability for acute coronary syndrome management and secondary prevention are important. Primary prevention should focus on tackling the social determinants of health as well as policy and individual interventions for risk factor control, supported by task sharing and use of technology.

Effect of coenzyme Q10 in Europeans with chronic heart failure: A sub-group analysis of the Q-SYMBIO randomized double-blind trial

BACKGROUND

Geographical differences in patient characteristics, management and outcomes in heart failure (HF) trials are well recognized. The aim of this study was to assess the consistency of the treat- ment effect of coenzyme Q10 (CoQ10) in the European sub-population of Q-SYMBIO, a randomized double-blind multinational trial of treatment with CoQ10, in addition to standard therapy in chronic HF.

METHODS

Patients with moderate to severe HF were randomized to CoQ10 300 mg daily or placebo in addition to standard therapy. At 3 months the primary short-term endpoints were changes in New York Heart Association (NYHA) functional classification, 6-min walk test, and levels of N-terminal pro-B type natriuretic peptide. At 2 years the primary long-term endpoint was major adverse cardiovascular events (MACE).

RESULTS

There were no significant changes in short-term endpoints. The primary long-term endpoint of MACE was reached by significantly fewer patients in the CoQ10 group (n = 10, 9%) compared to the placebo group (n = 33, 27%, p = 0.001). The following secondary endpoints were significantly improved in the CoQ10 group compared with the placebo group: all-cause and cardiovascular mortality, NYHA classification and left ventricular ejection fraction (LVEF). In the European sub-population, when compared to the whole group, there was greater adherence to guideline directed therapy and similar results for short- and long-term endpoints. A new finding revealed a significant improvement in LVEF.

CONCLUSIONS

The therapeutic efficacy of CoQ10 demonstrated in the Q-SYMBIO study was confirmed in the European sub-population in terms of safely reducing MACE, all-cause mortality, cardiovascular mortality, hospitalization and improvement of symptoms.

Low quality cardiovascular care is important coronary risk factor in India

Global Burden of Disease study has reported that cardiovascular and ischemic heart disease (IHD) mortality has increased by 34% in last 25 years in India. It has also been reported that despite having lower coronary risk factors compared to developed countries, incident cardiovascular mortality, cardiovascular events and case-fatality are greater in India. Reasons for the increasing trends and high mortality have not been studied. There is evidence that social determinants of IHD risk factors are widely prevalent and increasing. Epidemiological studies have reported low control rates of hypertension, hypercholesterolemia, diabetes and smoking/tobacco. Registries have reported greater mortality of acute coronary syndrome in India compared to developed countries. Secondary prevention therapies have significant gaps. Low quality cardiovascular care is an important risk factor in India. Package of interventions focusing on fiscal, intersectoral and public health measures, improvement of health services at community, primary and secondary healthcare levels and appropriate referral systems to specialized hospitals is urgently required.

Prevalence and control of cardiovascular risk factors in stable coronary artery outpatients in India compared with the rest of the world: An analysis from international CLARIFY registry

OBJECTIVES

We describe the clinical characteristics, prevalence and control of coronary artery disease (CAD) risk factors of the Indian cohort enrolled in the CLARIFY registry and compare them with data from rest of the world (ROW).

METHODS

CLARIFY is an international, prospective, observational, longitudinal cohort study in stable CAD outpatients. The baseline data of Indian cohort (n=709) were compared to ROW (n=31994).

RESULTS

The CLARIFY India patients were significantly younger than the ROW (59.6±10.9 vs 64.3±10.4). Indian patients were more likely than those in ROW to have diabetes (42.9% vs 28.8%) and angina (27.8% vs 21.9%). Mean heart rate was significantly greater in Indians measured by either palpatory method (76.1±10.4 vs 68.0±10.5) or ECG (74.9±12.9 vs 67.0±11.3). The use of aspirin (85.6% vs 87.8%), β-blockers (69.4% vs 75.4%), and lipid-lowering agents (90% vs 92.4%) was lower in India. A significantly greater proportion of patients in India exhibited low HDL cholesterol (41.6% vs 31.2%), and heart rate ≥70bpm (82.2% vs 48.5%). The risk factors control was poor in India with heart rate goal of ≤60bpm achieved in 2.5%; HbA1c <7% in 9.9%; and HbA1c <6.5% in 4.6% patients.

CONCLUSION

The CLARIFY registry demonstrates a high prevalence and poor control of cardiovascular risk factors in Indian patients. Systematic efforts to improve risk factor control are required.

Recent trends in epidemiology of dyslipidemias in India

Dyslipidemia is the most important atherosclerotic risk factor. Review of population based studies in India shows increasing mean total cholesterol levels. Recent studies have reported that high cholesterol is present in 25–30% of urban and 15–20% rural subjects. This prevalence is lower than high-income countries. The most common dyslipidemia in India are borderline high LDL cholesterol, low HDL cholesterol and high triglycerides. Studies have reported that over a 20-year period total cholesterol, LDL cholesterol and triglyceride levels have increased among urban populations. Case-control studies have reported that there is significant association of coronary events with raised apolipoproteinB, total cholesterol, LDL cholesterol and non-HDL cholesterol and inverse association with high apolipoproteinA and HDL cholesterol. Prevalence of suspected familial hypercholesterolemia in urban subjects varies from 1:125 to 1:450. Only limited studies exist regarding lipid abnormalities in children. There is low awareness, treatment and control of hypercholesterolemia in India.

Polypill: Progress and Challenges to Global Use--Update on the Trials and Policy Implementation

Cardiovascular disease (CVD) is the leading cause of mortality globally. Most people with cardiovascular disease do not take long-term cholesterol-lowering, anti-platelet and blood pressure-lowering medications despite proven benefits. Fixed-dose combination pills ('polypills') have been shown to improve adherence to these recommended medications with corresponding improvements in risk factors such as blood pressure and low-density lipoprotein (LDL) cholesterol. Among patients not taking the full complement of recommended CVD preventive therapies, use of a polypill-based strategy (i.e. initiating treatment with single-pill combination medication then titrating further therapy as needed) has large potential benefits in reducing global morbidity and mortality. Despite this, few polypills are available on the market due to market failure in the funding of research and development for affordable non-communicable disease medicines. Additionally, defining a path to market has been problematic in that fixed-dose combinations with multiple different drug classes included are quite novel, and regulatory processes to review these types of applications are not well established. Despite these delays, progress is slowly being made.

Non-physician health workers for improving adherence to medications and healthy lifestyle following acute coronary syndrome: 24-month follow-up study

Objective

To evaluate usefulness of non-physician health workers (NPHW) to improve adherence to medications and lifestyles following acute coronary syndrome (ACS).

Methods

We randomized 100 patients at hospital discharge following ACS to NPHW intervention (n = 50) or standard care (n = 50) in an open label study. NPHW was trained for interventions to improve adherence to medicines – antiplatelets, β-blockers, renin–angiotensin system (RAS) blockers and statins and healthy lifestyles. Intervention lasted 12 months with passive follow-up for another 12. Both groups were assessed for adherence using a standardized questionnaire.

Results

ST elevation myocardial infarction (STEMI) was in 49 and non-STEMI in 51, mean age was 59.0 ± 11 years. 57% STEMI were thrombolyzed. On admission majority were physically inactive (71%), consumed unhealthy diets (high fat 77%, high salt 58%, low fiber 57%) and 21% were smokers/tobacco users. Coronary revascularization was performed in 90% (percutaneous intervention 79%, bypass surgery 11%). Drugs at discharge were antiplatelets 100%, β-blockers 71%, RAS blockers 71% and statins 99%. Intervention and control groups had similar characteristics. At 12 and 24 months, respectively, in intervention vs control groups adherence (>80%) was: anti platelets 92.0% vs 77.1% and 83.3% vs 40.9%, β blockers 97.2% vs 90.3% and 84.8% vs 45.0%), RAS blockers 95.1% vs 82.3% and 89.5% vs 46.1%, and statins 94.0% vs 70.8% and 87.5% vs 29.5%; smoking rates were 0.0% vs 12.5% and 4.2% vs 20.5%, regular physical activity 96.0% vs 50.0%, and 37.5% vs 34.1%, and healthy diet score 5.0 vs 3.0, and 4.0 vs 2.0 (p < 0.01 for all). Intervention vs standard group at 12 months had significantly lower mean systolic BP, heart rate, body mass index, waist:hip ratio, total cholesterol, triglyceride, and LDL cholesterol (p < 0.01).

Conclusions

NPHW-led educational intervention for 12 months improved adherence to evidence based medicines and healthy lifestyles. Efficacy continued for 24 months with attrition.

Gender differences in 7 years trends in cholesterol lipoproteins and lipids in India: Insights from a hospital database

OBJECTIVE

To determine gender differences and secular trends in total, low-density lipoprotein (LDL) and high DL (HDL) cholesterol and triglycerides using a large hospital database in India.

METHODS

All blood lipid tests evaluated from July 2007 to December 2014 were analyzed. Details of gender and age were available. Statin therapy was obtained at two separate periods. Trends were calculated using linear regression and Mantel-Haenszel X(2).

RESULTS

Data of 67395 subjects (men 49,904, women 17,491) aged 51 ± 12 years were analyzed. Mean levels (mg/dl) were total cholesterol 174.7 ± 45, LDL cholesterol 110.7 ± 38, non-HDL cholesterol 132.1 ± 44.8, HDL cholesterol 44.1 ± 10, triglycerides 140.8 ± 99, and total: HDL cholesterol 4.44 ± 1.5. Various dyslipidemias in men/women were total cholesterol ≥200 mg/dl 25.4/36.4%, LDL cholesterol ≥130 mg/dl 28.1/35.0% and ≥100 mg/dl 54.4/66.4%, non-HDL cholesterol ≥160 mg/dl 25.5/29.6%, HDL cholesterol <40/50 mg/dl 54.4/64.4%, and triglycerides ≥150 mg/dl 34.0/26.8%. Cholesterol lipoproteins declined over 7 years with greater decline in men versus women for cholesterol (Blinear regression = -0.82 vs. -0.33, LDL cholesterol (-1.01 vs. -0.65), non-HDL cholesterol (-0.88 vs. -0.52), and total: HDL cholesterol (-0.02 vs. -0.01). In men versus women there was greater decline in prevalence of hypercholesterolemia (X(2) trend 74.5 vs. 1.60), LDL cholesterol ≥130 mg/dl (X(2) trend 415.5 vs. 25.0) and ≥100 mg/dl (X(2) trend 501.5 vs. 237.4), non-HDL cholesterol (X(2) trend 77.4 vs. 6.85), total: HDL cholesterol (X(2) trend 212.7 vs. 10.5) and high triglycerides (X(2) trend 10.8 vs. 6.15) (P < 0.01). Use of statins was in 2.6% (36/1405) in 2008 and 9.0% (228/2527) in 2014 (P < 0.01). Statin use was significantly lower in women (5.8%) than men (10.3%).

CONCLUSIONS

In a large hospital - database we observed greater hypercholesterolemia and low HDL cholesterol in women. Mean levels and prevalence of high total, LDL, non-HDL and total: HDL cholesterol declined over 7 years. A lower decline was observed in women. This was associated with lower use of statins.

Evaluation of statin prescriptions in type 2 diabetes: India Heart Watch-2

BACKGROUND

Contemporary treatment guidelines advise statin use in all patients with diabetes for reducing coronary risk. Use of statins in patients with type 2 diabetes has not been reported from India.

METHODS

We performed a multisite (n=9) registry-based study among internists (n=3), diabetologists (n=3), and endocrinologists (n=3) across India to determine prescriptions of statins in patients with type 2 diabetes. Demographic and clinical details were obtained and prescriptions were audited for various medications with a focus on statins. Details of type of statin and dosage form (low, moderate, and high) were obtained. Patients were divided into categories based on presence of cardiovascular risk into low (no risk factors, n=1506), medium (≥1 risk factor, n=5425), and high (with vascular disease, n=1769). Descriptive statistics are presented.

RESULTS

Prescription details were available in 8699 (men 5292, women 3407). Statins were prescribed in 55.2% and fibrates in 9.2%. Statin prescription was significantly greater among diabetologists (64.4%) compared with internists (n=53.3%) and endocrinologists (46.8%; p<0.001). Atorvastatin was prescribed in 74.1%, rosuvastatin in 29.2%, and others in 3.0%. Statin prescriptions were lower in women (52.1%) versus men (57.2%; p<0.001) and in patients aged <40 years (34.3%), versus those aged 40-49 (49.7%), 50-59 (60.1%), and ≥60 years (62.2%; p<0.001). Low-dose statins were prescribed in 1.9%, moderate dose in 85.4%, and high dose in 12.7%. Statin prescriptions were greater in the high-risk group (58.0%) compared with those in the medium-risk (53.8%) and low-risk (56.8%) groups (p <0.001). High-dose statin prescriptions were similar in the high-risk (14.5%), medium-risk (11.8%), and low-risk (13.5%) groups (p=0.31).

CONCLUSIONS

Statins are prescribed in only half of the clinic-based patients in India with type 2 diabetes. Prescription of high-dose statins is very low.

Reduced heart function predicts drug-taking compliance and two-year prognosis in chinese patients with stable premature coronary artery disease

Background

The purpose of this study was to determine the association between heart function, compliance with drug administration, and the mid-term prognosis in Chinese patients with stable premature coronary artery disease (CAD) (male < 55 years and female < 65 years).

Methods

The study included 512 patients with stable premature CAD. An estimated glomerular filtration rate (eGFR) calculated using the MDRD formula, baseline clinical characteristics, use of medications for coronary secondary prevention therapies (aspirin, β-blocker, angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers, or statins), and 2-year follow-up results, in particular major adverse cardiac events (MACEs), were collected and analyzed.

Results

Patients with reduced left ventricular ejection fraction (LVEF) (18.75%) were more prevalent among men, smokers, those with type 2 diabetes, with a family history of cardiovascular disease (CVD), and with higher white blood cells counts ((8.88 ± 0.35) × 10⁹/L vs. (6.90 ± 0.17) × 10⁹/L) (all P < 0.05) compared to those with preserved LVEF. There was no significant difference between creatinine or eGFR values in the two groups with reduced and preserved LVEF (all P > 0.05). Patients with LVEF < 50% in the MACEs group had a lower ratio of optimal drug administration compared to the MACEs-free group (Z = -0.228, P = 0.820 and Z = -2.167, P = 0.03 respectively). Patients with reduced LVEF had a significantly higher ratio of composite MACEs than patients with preserved LVEF during 2-year follow-up (47.13% vs. 33.50%, P < 0.05).

Conclusions

Stable premature CAD patients with reduced LVEF have more risk factors, lower medication compliance, and worse 2-year outcomes than those with preserved LVEF.

SMARTHealth India: Development and Field Evaluation of a Mobile Clinical Decision Support System for Cardiovascular Diseases in Rural India

Background

Cardiovascular disease (CVD) is the major cause of premature death and disability in India and yet few people at risk of CVD are able to access best practice health care. Mobile health (mHealth) is a promising solution, but very few mHealth interventions have been subjected to robust evaluation in India.

Objective

The objectives were to develop a multifaceted, mobile clinical decision support system (CDSS) for CVD management and evaluate it for use by public nonphysician health care workers (NPHWs) and physicians in a rural Indian setting.

Methods

Plain language clinical rules were developed based on standard guidelines and programmed into a computer tablet app. The algorithm was validated and field-tested in 11 villages in Andhra Pradesh, involving 11 NPHWs and 3 primary health center (PHC) physicians. A mixed method evaluation was conducted comprising clinical and survey data and in-depth patient and staff interviews to understand barriers and enablers to the use of the system. Then this was thematically analyzed using NVivo 10.

Results

During validation of the algorithm, there was an initial agreement for 70% of the 42 calculated variables between the CDSS and SPSS software outputs. Discrepancies were identified and amendments were made until perfect agreement was achieved. During field testing, NPHWs and PHC physicians used the CDSS to screen 227 and 65 adults, respectively. The NPHWs identified 39% (88/227) of patients for referral with 78% (69/88) of these having a definite indication for blood pressure (BP)-lowering medication. However, only 35% (24/69) attended a clinic within 1 month of referral, with 42% (10/24) of these reporting continuing medications at 3-month follow-up. Physicians identified and recommended 17% (11/65) of patients for BP-lowering medications. Qualitative interviews identified 3 interrelated interview themes: (1) the CDSS had potential to change prevailing health care models, (2) task-shifting to NPHWs was the central driver of change, and (3) despite high acceptability by end users, actual transformation was substantially limited by system-level barriers such as patient access to doctors and medicines.

Conclusions

A tablet-based CDSS implemented within primary health care systems has the potential to help improve CVD outcomes in India. However, system-level barriers to accessing medical care limit its full impact. These barriers need to be actively addressed for clinical innovations to be successful.

Trial Registration

Clinical Trials Registry of India: CTRI/2013/06/003753; http://ctri.nic.in/Clinicaltrials/showallp.php?mid1=6259&EncHid=51761.70513&userName=CTRI/2013/06/003753 (Archived by WebCite at http://www.webcitation.org/6UBDlrEuq).

Optimal in-hospital and discharge medical therapy in acute coronary syndromes in Kerala: results from the Kerala acute coronary syndrome registry

BACKGROUND

In-hospital and postdischarge treatment rates for acute coronary syndrome (ACS) remain low in India. However, little is known about the prevalence and associations of the package of optimal ACS medical care in India. Our objective was to define the prevalence, associations, and impact of optimal in-hospital and discharge medical therapy in the Kerala ACS Registry of 25,718 admissions.

METHODS AND RESULTS

We defined optimal in-hospital ACS medical therapy as receiving the following 5 medications: aspirin, clopidogrel, heparin, β-blocker, and statin. We defined optimal discharge ACS medical therapy as receiving all of the above therapies except heparin. Comparisons by optimal versus nonoptimal ACS care were made via Student t test for continuous variables and χ(2) test for categorical variables. We created random effects logistic regression models to evaluate the association between Global Registry of Acute Coronary Events risk score variables and optimal in-hospital or discharge medical therapy. Optimal in-hospital and discharge medical care were delivered in 40% and 46% of admissions, respectively. Wide variability in both in-hospital and discharge medical care was present, with few hospitals reaching consistently high (>90%) levels. Patients receiving optimal in-hospital medical therapy had an adjusted odds ratio (95% confidence interval)=0.93 (0.71, 1.22) for in-hospital death and an adjusted odds ratio (95% confidence interval)=0.79 (0.63, 0.99) for major adverse cardiovascular event rates. Patients who received optimal in-hospital medical care were far more likely to receive optimal discharge care (adjusted odds ratio [95% confidence interval] = 10.48 [9.37, 11.72]).

CONCLUSIONS

Strategies to improve in-hospital and discharge medical therapy are needed to improve local process-of-care measures and ACS outcomes in Kerala.

Epidemiology of cardioprotective pharmacological agent use in stable coronary heart disease

OBJECTIVE

To determine use of class and type of cardioprotective pharmacological agents in patients with stable coronary heart disease (CHD) we performed a prescription audit.

METHODS

A cross sectional survey was conducted in major districts of Rajasthan in years 2008-09. We evaluated prescription for classes (anti-platelets, β-blockers, angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARB), calcium channel blockers (CCB) and statins) and specific pharmacological agents at clinics of physicians in tertiary (n = 18), secondary (n = 69) and primary care (n = 43). Descriptive statistics are reported.

RESULTS

Prescriptions of 2290 stable CHD patients were audited. Anti-platelet use was in 2031 (88.7%), β-blockers 1494 (65.2%), ACE inhibitors 1196 (52.2%), ARBs 712 (31.1%), ACE inhibitors - ARB combinations 19 (0.8%), either ACE inhibitors or ARBs 1908 (83.3%), CCBs 1023 (44.7%), statins 1457 (63.6%) and other lipid lowering agents in 170 (7.4%). Among anti-platelets aspirin-clopidogrel combination was used in 88.5%. Top three molecules in β-blockers were atenolol (37.8%), metoprolol (26.4%) and carvedilol (11.9%); ACE inhibitors ramipril (42.1%), lisinopril (20.3%) and perindopril (10.9%); ARB's losartan (47.7%), valsartan (22.3%) and telmisartan (14.9%); CCBs amlodipine (46.7%), diltiazem (29.1%) and verapamil (9.5%) and statins were atorvastatin (49.8%), simvastatin (28.9%) and rosuvastatin (18.3%). Use of metoprolol, ramipril, valsartan, diltiazem and atorvastatin was more at tertiary care, and atenolol, lisinopril, losartan, amlodipine and simvasatin in primary care (p < 0.01).

CONCLUSIONS

There is low use of β-blockers, ACE inhibitors, ARBs and statins in stable CHD patients among physicians in Rajasthan. Significant differences in use of specific molecules at primary, secondary and tertiary healthcare are observed.

Influence of education and working background on physicians' knowledge of secondary prevention guidelines for coronary heart disease: results from a survey in China

BACKGROUND AND OBJECTIVE

In clinical practice, the standard of secondary prevention for coronary heart disease (CHD) is quite disappointing in China. The physicians' shortage of knowledge of secondary prevention guidelines is thought to be a key factor contributing to the inadequate and delayed translation of guidelines into clinical practice. The purpose of this study is to investigate the influence of physicians' characteristics, including their education and work experience, on their knowledge of secondary prevention in China.

METHODS

A representative questionnaire survey was made of physicians from cardiology departments in 35 tertiary hospitals in China. The survey contained 19 questions on knowledge of guideline recommendations for the secondary prevention of CHD. We collected basic information about the physicians, including their educational degree, clinical practice duration/work experience and geographic region.

RESULTS

In total, 864 physicians participated in the survey. Eight hundred and thirty-seven completed questionnaires were analyzed. For 6 of the 19 questions, physicians with a postgraduate degree were more likely to answer correctly than those without such a degree. For 11 of the 19 questions, physicians with more than three years' clinical experience were more likely to answer correctly than those who had less than three years' experience. For 5 of the 19 questions, physicians from eastern areas were more likely to answer correctly than those from mid/western areas. The mean total score of correct answers to the questionnaire was 11.69 points. Educational degree and clinical practice duration affected total scores significantly while practice location did not (β=0.500, P=0.004; β=0.979, P=0.000; and β=0.228, P=0.162, respectively). Even if a relatively low score of 12 is taken as a threshold level of acceptable knowledge (defined as a pass), the pass rate of all physicians was only 53.9%. Educational degree and clinical practice duration affected pass rate significantly while practice location did not (95% CI: 1.222-2.248, P=0.001; 95% CI: 1.773-3.140, P=0.000; and 95% CI: 0.993-1.758, P=0.056, respectively).

CONCLUSIONS

Physicians with a clinical practice duration of more than three years knew more about secondary prevention guidelines than those with less experience. Physicians with a postgraduate degree knew more about secondary prevention guidelines than those without a postgraduate degree. However, overall knowledge of secondary prevention guidelines for CHD was poor among this group of physicians from tertiary hospitals.

An international randomised placebo-controlled trial of a four-component combination pill ("polypill") in people with raised cardiovascular risk

BACKGROUND

There has been widespread interest in the potential of combination cardiovascular medications containing aspirin and agents to lower blood pressure and cholesterol ('polypills') to reduce cardiovascular disease. However, no reliable placebo-controlled data are available on both efficacy and tolerability.

METHODS

We conducted a randomised, double-blind placebo-controlled trial of a polypill (containing aspirin 75 mg, lisinopril 10 mg, hydrochlorothiazide 12.5 mg and simvastatin 20 mg) in 378 individuals without an indication for any component of the polypill, but who had an estimated 5-year cardiovascular disease risk over 7.5%. The primary outcomes were systolic blood pressure (SBP), LDL-cholesterol and tolerability (proportion discontinued randomised therapy) at 12 weeks follow-up.

FINDINGS

At baseline, mean BP was 134/81 mmHg and mean LDL-cholesterol was 3.7 mmol/L. Over 12 weeks, polypill treatment reduced SBP by 9.9 (95% CI: 7.7 to 12.1) mmHg and LDL-cholesterol by 0.8 (95% CI 0.6 to 0.9) mmol/L. The discontinuation rates in the polypill group compared to placebo were 23% vs 18% (RR 1.33, 95% CI 0.89 to 2.00, p = 0.2). There was an excess of side effects known to the component medicines (58% vs 42%, p = 0.001), which was mostly apparent within a few weeks, and usually did not warrant cessation of trial treatment.

CONCLUSIONS

This polypill achieved sizeable reductions in SBP and LDL-cholesterol but caused side effects in about 1 in 6 people. The halving in predicted cardiovascular risk is moderately lower than previous estimates and the side effect rate is moderately higher. Nonetheless, substantial net benefits would be expected among patients at high risk.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12607000099426.

The scope of cell phones in diabetes management in developing country health care settings

Diabetes has emerged as a major public health concern in developing nations. Health systems in most developing countries are yet to integrate effective prevention and control programs for diabetes into routine health care services. Given the inadequate human resources and underfunctioning health systems, we need novel and innovative approaches to combat diabetes in developing-country settings. In this regard, the tremendous advances in telecommunication technology, particularly cell phones, can be harnessed to improve diabetes care. Cell phones could serve as a tool for collecting information on surveillance, service delivery, evidence-based care, management, and supply systems pertaining to diabetes from primary care settings in addition to providing health messages as part of diabetes education. As a screening/diagnostic tool for diabetes, cell phones can aid the health workers in undertaking screening and diagnostic and follow-up care for diabetes in the community. Cell phones are also capable of acting as a vehicle for continuing medical education; a decision support system for evidence-based management; and a tool for patient education, self-management, and compliance. However, for widespread use, we need robust evaluations of cell phone applications in existing practices and appropriate interventions in diabetes.

Translating evidence into policy for cardiovascular disease control in India

Cardiovascular diseases (CVD) are leading causes of premature mortality in India. Evidence from developed countries shows that mortality from these can be substantially prevented using population-wide and individual-based strategies. Policy initiatives for control of CVD in India have been suggested but evidence of efficacy has emerged only recently. These initiatives can have immediate impact in reducing morbidity and mortality. Of the prevention strategies, primordial involve improvement in socioeconomic status and literacy, adequate healthcare financing and public health insurance, effective national CVD control programme, smoking control policies, legislative control of saturated fats, trans fats, salt and alcohol, and development of facilities for increasing physical activity through better urban planning and school-based and worksite interventions. Primary prevention entails change in medical educational curriculum and improved healthcare delivery for control of CVD risk factors-smoking, hypertension, dyslipidemia and diabetes. Secondary prevention involves creation of facilities and human resources for optimum acute CVD care and secondary prevention. There is need to integrate various policy makers, develop effective policies and modify healthcare systems for effective delivery of CVD preventive care.

Impact of the CD40-CD40L dyad in Alzheimer's disease

As the number of elderly individuals rises, Alzheimer's disease (AD), marked by amyloid-beta deposition, neurofibrillary tangle formation, and low-level neuroinflammation, is expected to lead to an ever-worsening socioeconomic burden. AD pathoetiologic mechanisms are believed to involve chronic microglial activation. This phenomenon is associated with increased expression of membrane-bound CD40 with its cognate ligand, CD40 ligand (CD40L), as well as increased circulating levels of soluble forms of CD40 (sCD40) and CD40L (sCD40L). Here, we review the role of this inflammatory dyad in the pathogenesis of AD. In addition, we examine potential therapeutic strategies such as statins, flavonoids, and human umbilical cord blood transplantation, all of which have been shown to modulate CD40-CD40L interaction in mouse models of AD. Importantly, therapeutic approaches focusing on CD40-CD40L dyad regulation, either alone or in combination with amyloid-beta immunotherapy, may provide for a safe and effective AD prophylaxis or treatment in the near future.