Care Of Cardiovascular Risk Factors Research Articles

The Fourth Trimester: a Time for Enhancing Transitions in Cardiovascular Care.

Purpose of ReviewThe “fourth trimester” concept, defined as the first 12 weeks after delivery (and beyond), is a critical window of time for clinicians to intervene to optimize women’s cardiovascular health after pregnancy. A timely and comprehensive postpartum cardiovascular assessment should be performed in all women following delivery in order to (1) follow up medical conditions present prior to conception, (2) evaluate symptoms and signs of common postpartum complications, and (3) identify risk factors and prevent future adverse cardiovascular outcomes. In this review, we aim to discuss major maternal cardiovascular risk factors such as hypertensive disorders of pregnancy, gestational diabetes mellitus, postpartum weight retention, and postpartum depression, as well as lactation as a potential protective risk modifying factor. Additionally, we will review effectiveness of outpatient interventions to enhance transitions in cardiovascular care during the fourth trimester.Recent FindingsA seamless hand-off from obstetric to primary care, and potentially cardiology, is needed for early detection and management of hypertension, weight, glycemic control, stress and mood, and long-term cardiovascular risk. Additionally, the use of telemedicine, blood pressure self-monitoring, remote activity monitoring, and behavioral health coaches are potentially feasible modalities to augment clinic-based care for cardiovascular risk factors and weight management, but additional studies are needed to study their long-term effectiveness.SummaryDevelopment of a comprehensive postpartum care plan with careful consideration of each patient’s risk profile and access to resources is critical to improve maternal morbidity and mortality, reduce health disparities, and achieve long-term cardiovascular health for women. Supporting postpartum well-being of women during this transition period requires a multidisciplinary approach, especially primary care engagement, and planning should start before delivery.

Prevalence and access to care for cardiovascular risk factors in older people in Sierra Leone: a cross-sectional survey.

IntroductionPrevalence of cardiovascular disease risk factors (CVDRFs) is increasing, especially in low-income countries. In Sierra Leone, there is limited empirical data on the prevalence of CVDRFs, and there are no previous studies on the access to care for these conditions.MethodsThis study in rural and urban Sierra Leone collected demographic, anthropometric measurements and clinical data from randomly sampled individuals over 40 years old using a household survey. We describe the prevalence of the following risk factors: diabetes, hypertension, dyslipidaemia, overweight or obesity, smoking and having at least one of these risk factors. Cascades of care were constructed for diabetes and hypertension using % of the population with the disease who had previously been tested (‘screened’), knew of their condition (‘diagnosed’), were on treatment (‘treated’) or were controlled to target (‘controlled’). Multivariable regression was used to test associations between prevalence of CVDRFs and progress through the cascade for hypertension with demographic and socioeconomic variables. In those with recognised disease who did not seek care, reasons for not accessing care were recorded.ResultsOf 2071 people, 49.6% (95% CI 49.3% to 50.0%) of the population had hypertension, 3.5% (3.4% to 3.6%) had diabetes, 6.7% (6.5% to 7.0%) had dyslipidaemia, 25.6% (25.4% to 25.9%) smoked and 26.5% (26.3% to 26.8%) were overweight/obese; a total of 77.1% (76.6% to 77.5%) had at least one CVDRF. People in urban areas were more likely to have diabetes and be overweight than those living in rural areas. Moreover, being female, more educated or wealthier increased the risk of having all CVDRFs except for smoking. There is a substantial loss of patients at each step of the care cascade for both diabetes and hypertension, with less than 10% of the total population with the conditions being screened, diagnosed, treated and controlled. The most common reasons for not seeking care were lack of knowledge and cost.ConclusionsIn Sierra Leone, CVDRFs are prevalent and access to care is low. Health system strengthening with a focus on increased access to quality care for CVDRFs is urgently needed.

Niveau de vigilance des psychiatres pour les facteurs de risque cardiovasculaire chez les patients schizophrènes

Schizophrenic patients have increased cardiovascular risk factors and morbi-mortality as compared with the general population. To assess the level of French psychiatrists vigilance regarding cardiovascular risk factors in schizophrenic patients. Prospective, transverse, multicentric observational study implemented in France in 2007 and conducted by psychiatrists with a liberal activity. The included patients had to meet the following selection criteria: patients ≥ 18 years old, fulfilling the DSM-IV-TR criteria for schizophrenia, treated or not treated for their schizophrenia, with an ambulatory follow-up, without schizophreniform, schizoaffective, or other psychotic disorder. The psychiatrists "vigilance level" for a given cardiovascular risk factor was defined as a systematic investigation of this cardiovascular risk factor for at least 75% of the schizophrenic patients included in the study by the psychiatrist. A total of 382 psychiatrists included 2242 patients, the data collected for 2222 patients were finally analysed. The mean age was 41 years old, 59% were men. The mean BMI was 27 kg/m(2), 34% of the patients were overweight, 23% were obese. The paranoid and residual schizophrenia were the most frequently described subtypes of the disease (41.3 and 25.0% respectively), 58% of the patients were moderately or markedly ill according to the CGI-S scale. Most of the patients were treated with atypical antipsychotics (77%). Only 58% of the psychiatrists were vigilant for the weight of their patients, 38% for the arterial tension, 25% for the family history of premature coronary disease, 14% for the glycemia, 12% for the triglycerides, 10% for HDL cholesterol, 6% for the waist measurement; 35% of the psychiatrists were vigilant for no cardiovascular risk factor. Less than 30% of the psychiatrists recommended their patients to other specialists to manage cardiovascular disorders. Similarly to other countries, French psychiatrists provide insufficient care of cardiovascular risk factors of schizophrenic patients in their current clinical practice.

The lower quality of preventive care among forced migrants in a country with universal healthcare coverage

ObjectiveTo assess the association between socio-demographic factors and the quality of preventive care and chronic care of cardiovascular (CV) risk factors in a country with universal health care coverage. MethodsOur retrospective cohort assessed a random sample of 966 patients aged 50–80years followed over 2years (2005–2006) in 4 Swiss university primary care settings (Basel/Geneva/Lausanne/Zürich). We used RAND's Quality Assessment Tools indicators and examined recommended preventive care among different socio-demographic subgroups. ResultsOverall patients received 69.6% of recommended preventive care. Preventive care indicators were more likely to be met among men (72.8% vs. 65.4%; p<0.001), younger patients (from 71.0% at 50–59years to 66.7% at 70–80years, p for trend=0.03) and Swiss patients (71.1% vs. 62.7% in forced migrants; p=0.001). This latter difference remained in multivariate analysis adjusted for gender, age, civil status and occupation (OR 0.68; 95% CI 0.54–0.86). Forced migrants had lower scores for physical examination and breast and colon cancer screening (all p≤0.02). No major differences were seen for chronic care of CV risk factors. ConclusionDespite universal healthcare coverage, forced migrants receive less preventive care than Swiss patients in university primary care settings. Greater attention should be paid to forced migrants for preventive care.

The Quality of Primary Care in a Country with Universal Health Care Coverage

Standard indicators of quality of care have been developed in the United States. Limited information exists about quality of care in countries with universal health care coverage. To assess the quality of preventive care and care for cardiovascular risk factors in a country with universal health care coverage. Retrospective cohort of a random sample of 1,002 patients aged 50-80 years followed for 2 years from all Swiss university primary care settings. We used indicators derived from RAND's Quality Assessment Tools. Each indicator was scored by dividing the number of episodes when recommended care was delivered by the number of times patients were eligible for indicators. Aggregate scores were calculated by taking into account the number of eligible patients for each indicator. Overall, patients (44% women) received 69% of recommended preventive care, but rates differed by indicators. Indicators assessing annual blood pressure and weight measurements (both 95%) were more likely to be met than indicators assessing smoking cessation counseling (72%), breast (40%) and colon cancer screening (35%; all p < 0.001 for comparisons with blood pressure and weight measurements). Eighty-three percent of patients received the recommended care for cardiovascular risk factors, including >75% for hypertension, dyslipidemia and diabetes. However, foot examination was performed only in 50% of patients with diabetes. Prevention indicators were more likely to be met in men (72.2% vs 65.3% in women, p < 0.001) and patients <65 years (70.1% vs 68.0% in those ≥ 65 years, p = 0.047). Using standardized tools, these adults received 69% of recommended preventive care and 83% of care for cardiovascular risk factors in Switzerland, a country with universal coverage. Prevention indicator rates were lower for women and the elderly, and for cancer screening. Our study helps pave the way for targeted quality improvement initiatives and broader assessment of health care in Continental Europe.

Aorta of young and middle-aged heterozygous familial hypercholesterolemia patients shows no functional or morphological impairment assessed by MRI

In familial hypercholesterolemia (FH) the level of LDL cholesterol is 2-3 times that of the normal population and leads to accelerated atherosclerosis. Improved care for risk factors has decreased cardiovascular mortality of these patients. We studied subclinical atherosclerotic changes with morphologic and functional aortic magnetic resonance imaging (MRI) in FH patients under the age of 50.39 DNA test-verified heterozygous FH-North Karelia patients, aged 6-48, 28 of them treated with statins, and 25 healthy controls, aged 12 to 50, underwent aortic MRI, carotid ultrasound (US), and risk-factor assessment. No differences in any of the morphologic or functional aortic parameters appeared between patients and controls. Age and gender were independent predictors of the majority of the morphologic and functional measures. Carotid intima-media thickness assessed by US was greater in patients (0.57 mm +/- 0.13 vs. 0.48 +/- 0.13 mm, p = 0.005) as was cholesterol-years score (243 +/- 122 vs. 137 +/- 74, p < 0.001). Patients had thicker intima-media of the common carotid artery and higher cholesterol burden as indicated by their cholesterol-years score. Despite this, no differences existed in morphologic or functional aortic parameters assessed with MRI. The improved care of cardiovascular risk factors, especially statin treatment, may protect the aorta of FH patients. However, larger confirmatory studies are needed.

Los ciclos de mejora de calidad en la atención al paciente hipertenso: Ciclo-Risk Study

Fundamentos: Con frecuencia encontramos deficiencias en el manejo de los factores de riesgo en las personas hipertensas. El objetivo del estudio fue evaluar el efecto de una intervencion de mejora de calidad en la atencion a los factores de riesgo cardiovascular en personas hipertensas. Metodos: Estudio de mejora de calidad. Dos centros de salud y catorce medicos de familia. Un centro (siete medicos) se selecciono para recibir una intervencion de mejora de calidad y otro como grupo control. Se incluyo a 482 personas hipertensas en el grupo de estudio [64% mujeres, edad media 61,4 anos (DS:6.8)] y 360 en el grupo control (63% mujeres, edad media 60,7 (DS:7.4)). La intervencion consistio en una auditoria de historias clinicas con feedback, sesiones de entrenamiento y discusion de guias clinicas. Previamente a la intervencion y un ano despues de la misma se evaluaron criterios de proceso de atencion a personas hipertensas, presion arterial, peso, lipidos, tabaco, riesgo cardiovascular y farmacos antihipertensivos. Resultados: La mejora media en el proceso despues de la intervencion fue de 5,3 puntos porcentuales (CI95%:3,7-6,9). La presion arterial sistolica descendio 3,5 mmHg (IC95%:1,6-5,3) y la presion arterial diastolica 2,5 mmHg (IC95%:1,3-3,8). El control adecuado de la presion arterial se incremento en el grupo de intervencion (29,1% a 40,9%; p<0.01) y no hubo cambios en el grupo control. El riesgo cardiovascular descendio en el grupo de intervencion (15,86 a 14,34%, P<0.01) y en el grupo control no vario. El riesgo absoluto descendio 2,07(IC95%:1,21-2,93) y el relativo 0,25 puntos porcentuales (IC95%:0,14-0,35). Conclusiones: La intervencion fue efectiva en la mejora de calidad de atencion al proceso asistencial al haber descendido la presion arterial y el riesgo cardiovascular, tanto absoluto como relativo.

Advances in the Invasive Diagnosis and Treatment of Vulnerable Coronary Plaques

To date, cardiologists have alleviated the symptoms of patients with significant lesions in the coronary angiography by stenting or coronary artery bypass grafting. While normal-looking coronary segments in angiography have been regarded as ‘disease-free’ and mild/moderate stenoses as ‘non-treatable’, today that we know that from these non-significantly diseased areas may potentially arise acute coronary events if no further action is taken other than standard care for cardiovascular risk factors.