Diagnosis and management of atrial fibrillation by primary care physicians in Italy : a retrospective, observational analysis

Background

Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with a heavy burden of morbidity and mortality, mainly due to an increased risk of cerebrovascular events and cardiac failure. Oral anticoagulant (OAC) treatment prevents stroke and systemic thromboembolism in patients with AF and its use is strongly recommended in guidelines. However, its use in this patient group remains limited. Primary care physicians (PCPs) have an important role to play in this context.

Objective

The primary objective was to estimate prevalence and epidemiological features of AF in the primary care setting, focusing on ischaemic and bleeding risk assessment. A secondary objective was to examine the PCPs’ level of adherence to the guidelines for the prevention of thromboembolic risk in these patients.

Methods

This retrospective, observational study was based on data entered by 128 PCPs into the Health Search (HS) Thales database, identifying patients with a diagnosis of AF at the time of the analysis.

Results

Out of 167,056 patients analysed, 2,173 (1.3 %) were diagnosed with AF, with 86 % at high risk for ischaemic stroke, according to CHA₂DS₂-VASc (congestive heart failure, hypertension, age ≥75 years [doubled], diabetes, stroke [doubled], vascular disease, age 65–74 years, sex category [female]) stratification. After the diagnosis of AF, 84 % of patients were prescribed OAC treatment. However, at 2 years’ follow-up, only 29.6 % were still being treated with OACs.

Conclusion

The prevalence of AF in this analysis was consistent with previously reported Italian national epidemiological data. Adherence to the European Society of Cardiology AF guidelines by PCPs was low, despite the high levels of stroke risk. At the end of the observation period less than one-third of patients were still on OAC therapy. Awareness of the benefits of OACs in stroke prevention in AF patients needs to be improved.

Knowledge of cardiovascular risk factors and awareness of non-pharmacological approach for risk prevention in young survivors of acute myocardial infarction. The cardiovascular risk prevention project "Help Your Heart Stay Young"

BACKGROUND AND AIMS

Knowledge of cardiovascular disease (CVD) risk factors in young patients who experienced myocardial infarction (MI) is poorly described.

METHODS AND RESULTS

Knowledge of traditional CVD risk factors, non-fatal cardiovascular events and of non-pharmacological factors able to reduce CVD risk and education level were evaluated by questionnaires in subjects who visited their family doctors. Sixty-one participants with history of MI in age <50 years (MI+) were compared with 3749 subjects with age <50 years, from the same population source, but without history of MI (MI-). MI+ were more frequently men (p<0.01), did not have significantly higher prevalences of family history of CVD, diabetes and hypertension. MI+ individuals reported previous non-fatal stroke (13% vs. 0.5%, p<0.001), overweight, diabetes, and hypercholesterolemia (all p<0.001) more frequently than controls, whereas prevalence of arterial hypertension, smoking habit and physical inactivity did not differ between the two groups; MI+ and MI- individuals did not differ in terms of the proportion of those who were unaware of being hypertensive, diabetic or hypercholesterolemic. MI+ participants reported more frequently lower education level than controls (p<0.05). Knowledge of non-pharmacological approach for CVD risk reduction was similar in MI+ and MI-. In a logistic multivariate analysis, male gender (adjusted odds ratio=5.8) and high cholesterol level (adjusted odds ratio 2.8, both p<0.01) were independent correlates of MI+. CVD risk factors distribution was similar between participants with juvenile MI+ and MI in age >or=50 years (n=167) extracted from the same population source; however, stroke was reported more frequently in juvenile MI+ than in those who had MI at age >or=50 years/old (13% vs. 4%, p<0.01).

CONCLUSIONS

Juvenile non-fatal MI was associated with metabolic CVD risk factors, with higher cerebrovascular co-morbidity and lower education level.

Individuals' cardiovascular risk profile projected by family doctors and individuals' knowledge of cardiovascular risk factors: a challenge for primary prevention. The cardiovascular risk prevention project "Help Your Heart Stay Young"

BACKGROUND

Whether the practice of family doctors of assessing individuals' cardiovascular risk profile improves individuals' knowledge of risk factors in primary prevention has not been established. Accordingly, we evaluated patients' knowledge of cardiovascular risk factors and lifestyle in healthy subjects whose family doctors provided individual cardiovascular risk score.

METHODS

Subjects who visited their family doctor in a time frame of 3 months, who accepted to fill-in a simple questionnaire measuring their knowledge of cardiovascular risk factors and of non-pharmacological interventions able to reduce cardiovascular risk were evaluated.

RESULTS

Fifty-one family doctors were involved. The study sample comprised 4239 subjects (mean age 56 +/- 9 years, 62% women) in primary prevention. They were classified by their family doctors, based on the Framingham algorithm, as being at low (< 10%; 45.7% of subjects), medium (10-20%; 38.7% of subjects) or moderate-to-high (> 20%; 15.6% of subjects) cardiovascular risk. The prevalence of obese subjects (40, 48, and 49%, respectively) and of heavy smokers (> or = 20 cigarettes/day; 26, 30, and 34%) increased from the low to the moderate-to-high risk group (both p < 0.05). The proportion of subjects unaware of personal history of arterial hypertension (5, 6, and 9%) and that of subjects who were unaware of history of elevated cholesterol levels (10, 11, and 12%, both p < 0.01) increased with higher cardiovascular risk score. The proportion of subjects self-reporting blood pressure > 135/85 mmHg, but self-reporting being normotensive (30, 50, and 52%), and the proportion of subjects who referred cholesterol levels > 200 mg/dl among those who self-referred not to have elevated cholesterol levels (13, 25, and 31%) increased both with cardiovascular risk category (p < 0.001). The proportion of subjects who were unaware of their personal history of diabetes was similar in the cardiovascular risk groups. The prevalence of low educational level was higher (56, 58, and 62%, p < 0.01) and the level of knowledge of non-pharmacological remedies to cardiovascular risk factors (63, 61, and 59%, p < 0.01) was lower in higher cardiovascular risk score group. Subjects aged < 55 years showed similar lack of knowledge about cardiovascular risk factors and the proportion of heavy smoking was as high as in the group of older participants.

CONCLUSIONS

In cardiovascular primary prevention, the projection of higher individuals' risk profile by family doctors was not paralleled by an increase in individual's knowledge of major cardiovascular risk factors and of lifestyle interventions able to reduce the cardiovascular risk.

Cardiovascular secondary prevention: patients' knowledge of cardiovascular risk factors and their attitude to reduce the risk burden, and the practice of family doctors. The "Help Your Heart Stay Young" study

BACKGROUND

Whether the practice of family doctors of assessing the global cardiovascular risk profile improves the knowledge of cardiovascular risk factors and the attitude to lifestyle change in patients' secondary cardiovascular prevention is unknown.

METHODS

We evaluated subjects who visited their family doctors and those with self-reported cardiovascular disease in the urban area of Naples, Italy. Patients self-administered a simple standard questionnaire to evaluate their knowledge of cardiovascular risk factors and of simple lifestyle modifications to reduce the cardiovascular risk burden. For each participant, family doctors, blinded to the information provided by patients, had to provide a global coronary risk based on the risk factors recorded in their electronic database, or report the missing information.

RESULTS

The study sample comprised 560 subjects, 61% male, with mean age 60 +/- 9 years. Angina pectoris (49%) and myocardial infarction (40.9%) were the most frequently self-reported cardiovascular diseases in the study sample. The self-reported data revealed that 46% of the sample was overweight and an additional 20% overtly obese. Among those who self-reported arterial hypertension, approximately 11% admitted that they were unaware of their blood pressure, and 26% believed that they were normotensive but reported a recently detected blood pressure > 140/90 mmHg. Approximately 8% were not aware of whether they had high cholesterol levels, and among those who declared having normal cholesterol levels, 9% referred levels > 200 mg/dl. Of the sample, 22% self-reported diabetes, but 7% did not know whether they were diabetic or not. Thirty percent of the sample were smokers and among these, 40% smoked > 20 cigarettes/day. A low level of education was reported in 66% of the study sample. Women were more frequently obese, more often reported high cholesterol levels, had a low level of education and achieved a lower score from the questionnaire on knowledge of cardiovascular risk factors than men. Patients > 55 years more often reported an elevated blood pressure among those who defined themselves as normotensive, and achieved a lower score from the questionnaire on knowledge of cardiovascular risk factors than younger patients.

CONCLUSIONS

With regard to secondary cardiovascular prevention, the study population was found to have insufficient knowledge of cardiovascular risk factors and of the correct approach to reduce their global risk despite the fact that the attitude of their family doctors in detecting and recording risk factors was above average.

Citizens and family doctors facing awareness and management of traditional cardiovascular risk factors: results from the Global Cardiovascular Risk Reduction Project (Help Your Heart Stay Young Study)

BACKGROUND AND AIM

The numerous guidelines and multiple approaches to managing cardiovascular risk factors have reduced the number of fatal events but not the incidence of cardiovascular disease (CVD). One rarely explored aspect is the extent to which individuals perceive their own risk in relation to their education and history of CVD. Furthermore, Italy has a State-based Health System, in which family doctors (FDs) may be an extremely useful and relatively low cost resource for risk management, but the degree of their involvement in individual CVD risk management has not been previously assessed.

METHODS AND RESULTS

The Department of Clinical and Experimental Medicine of Federico II University, Naples, Italy, and the Neapolitan Section of the Italian Society of Family Doctors (SIMG), developed an epidemiological survey to evaluate the level and awareness of CVD risk in subjects in the urban area of Naples, and the degree of involvement of FDs in CVD risk management. During a period of a few months, the subjects who visited their FDs were invited to respond to a standard self-explanatory questionnaire, and the FDs were required to provide quantitative information concerning the CVD risk factors of each enrolled subject from their databases in order to assess global CVD risk. The data included cholesterol and blood pressure (BP) levels, and had to be collected within six months of the visit; if the date were missing, the fact was recorded. The present analysis was based on data concerning the 5,687 subjects who had entered the study by January 2002, 7.6% of whom reported CVD (myocardial infarction (MI), stroke, angina, cerebral transient ischemic attack: CD+) and 92.4% did not (CVD-). MI was the most frequent CVD, and 18% of the CVD+ cases reported more than one non-fatal cardiovascular event. On average, the CVD+ subjects were older and more often men. After adjusting for age and FD, they also had a higher body mass index (BMI) and prevalence of obesity, higher self-reported BP, a lower education level, and more often referred high cholesterol levels, hypertension and diabetes. On the contrary, the proportion of smokers was higher in the CVD- group. Among the subjects who declared that they did not have a high cholesterol level, 11% reported recent values of > 200 mg/dL. The FDs of 36% of the cases were unable to assess the individual global CV risk level using quantitative data from their electronic databases. The most frequently missing information was the level of total cholesterol. Missing data were more frequent in the CVD- than the CVD+ subjects, regardless of age and FD.

CONCLUSIONS

The results of our study suggest that the awareness of CVD risk among subjects is somewhat vague. The FDs were generally able to provide a quantitative assessment of CVD risk in their patients. CVD risk prevention programmes may be more successful if they stress knowledge and awareness in the population, and stimulate FDs to undertake more stringent quantitative assessments of CVD risk factors.

Ketanserin, a new blocking agent of serotonin S2-receptors. Respiratory functional effects in chronic obstruction of the airways

The role played by serotonin (5-HT) in the regulation of bronchomotor tone has up to now been a much debated question, although there is good evidence that it induces intense bronchoconstriction after inhalation in asthmatic patients. Serotonin has been found to contract the tracheobronchial smooth muscle of different animals. Some data suggest that tracheobronchial contraction due to serotonin is mediated by its interaction with the S2-receptor. The blockade of this receptor by ketanserin, a serotoninergic antagonist which primarily binds to S2-serotoninergic receptors, produces bronchodilation. The respiratory effects of intravenously administered ketanserin (10 mg) or placebo were compared in a double-blind crossover study in 14 patients with chronic obstruction of the airways. The forced expiratory volume in one second (FEV1) and the instantaneous forced expiratory flow after 50 percent of the forced vital capacity has been exhaled (FEF50%) did not change after placebo, but they increased significantly after administration of ketanserin. The results suggest that in patients with chronic obstructive pulmonary disease, serotonin may play a role in the development of obstruction of the airways, even if the mechanism remains undefined.