Differences In Risk Factor Control Research Articles

Abstract P389: Prevalence, Awareness, Treatment, and Control of Major Cardiovascular Risk Factors in Rural Alabama

Background: CVD rates are high across the rural southern United States, but less is known about risk factor prevalence and control. Using data from two rural Alabama counties, we measured the prevalence, awareness, treatment, and control of hypertension, high cholesterol, and diabetes. Methods: The Risk Underlying Areas Longitudinal (RURAL) Heart and Lung Study began in 2021 to assess cardiopulmonary risk across 10 rural southern US counties. This analysis used data from two Alabama counties (N=942), 70% women, 79% non-Hispanic Black individuals, mean age 48.7 years. Hypertension was defined as SBP≥130 mmHg, DBP≥80 mmHg, and/or self-reporting hypertension medication use. High cholesterol was defined as TC≥200 mg/dL and/or cholesterol medication use. Diabetes was defined as fasting glucose≥126 mg/dL, non-fasting glucose>200 mg/dL, and/or diabetes medication use. Awareness, treatment, and control were assessed via self-reported physician diagnoses and medication use. All analyses applied sampling weights to produce representative estimates. Results: In the RURAL Alabama sample, the prevalence of hypertension was 73.7%, high cholesterol was 59.5%, and diabetes was 25.4%. The majority of individuals were aware of and taking medication for these risk factor conditions, but one-quarter of hypertension and less than half of diabetes was controlled (Figure). There were no significant sex differences observed. As compared with white individuals, Black individuals had a significantly higher prevalence of hypertension (79.2% vs 61.9%, p<0.001) and diabetes (29.9% vs 17.0%, p=0.005); however, there were no significant racial differences in risk factor control. Conclusion: There was a high prevalence of CVD risk factors in rural Alabama, with Black-white racial disparities for hypertension and diabetes, and control was low. This underscores the need for primary prevention of risk factors in the rural south and elucidating factors contributing to ‘treatment-control’ gaps for managing hypertension and diabetes.

Baseline Cardiovascular Risk Factor Control in Patients With Type 2 Diabetes and Coronary Disease Versus Stroke: Secondary Analysis of Cardiovascular Outcome Trials.

Patients with type 2 diabetes (T2D) and cardiovascular disease are at increased risk for recurrent ischemic events. Cardiovascular risk factor control is vital for secondary prevention, but how this compares among individuals with different T2D macrovascular complications is unknown. We aimed to determine if there might be differences in risk factor control in patients with T2D with previous stroke versus coronary artery disease (CAD). Cross-sectional analyses were performed on 12 856 patients with T2D with prior history of stroke with or without CAD from 3 diabetes cardiovascular outcome trials: CARMELINA (The Cardiovascular and Renal Microvascular Outcome Study With Linagliptin), EMPA-REG OUTCOME (Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients), and CAROLINA (The Cardiovascular Outcome Study of Linagliptin vs Glimepiride in Type 2 Diabetes). Risk factors at baseline assessed included dyslipidemia, hypertension, smoking, and current antiplatelet/anticoagulant therapy. Control, respectively, was defined as LDL (low-density lipoprotein)-C <100 mg/dL or statin use, systolic blood pressure <140 and diastolic blood pressure <90 mm Hg, not currently smoking, and use of an antiplatelet/anticoagulant medication. The odds ratio of 3 to 4 (or good) versus 0 to 2 (or suboptimal) risk factors controlled was analyzed by logistic regression models. The odds for good versus suboptimal risk factor control in patients with CAD alone was higher than in those with stroke alone across all 3 trials odds ratios (95% CI): CARMELINA, 2.05 (1.67-2.51), EMPA-REG OUTCOME, 2.50 (2.10-2.99), and CAROLINA, 1.63 (1.21-2.20). The respective odds ratios were lower (and rendered nonsignificant in CAROLINA) when cardiovascular risk factor control in patients with both CAD and stroke were compared with those with stroke alone: CARMELINA, 1.45 (1.13-1.87); EMPA-REG OUTCOME, 1.62 (1.25-2.08); and CAROLINA, 1.16 (0.74-1.83). In contemporary populations of patients with T2D, there was significant discordance in control of cardiovascular risk factors between patients with stroke versus CAD, with the former having less optimal control. The intermediate results in patients with both CAD and stroke suggest that these differences could be related at least in part to clinician factors. URL: https://www. gov; Unique identifiers: NCT01243424, NCT01131676, NCT01897532.

Abstract TP123: Baseline Differences in Risk Factor Control Between CREST-2 and SAMMPRIS

Baseline Differences in Risk Factor Control and Medication Use Between 2 Trials Employing Intensive Medical Management (SAMMPRIS &amp; CREST2) Background: The CREST2 trial Intensive Medical Management (IMM) protocol was adapted from the SAMMPRIS trial. However, since the 2011 publication of initial results of SAMMPRIS, there has been a greater appreciation for the importance of risk factor control in patients at risk of stroke associated with atherosclerosis. Therefore, we sought to determine differences in baseline risk factor control and medication use between SAMMPRIS and CREST2. Methods: Baseline risk factor and medication use data from 451 patients enrolled in SAMMPRIS (2008-2011) with severe symptomatic intracranial atherosclerosis and 1473 patients enrolled in CREST2 (2014-2019) with severe asymptomatic carotid stenosis were compared using the Chi-square test and t-test. Results: The Table shows baseline risk factor values and medications. SAMMPRIS patients were younger but had significantly worse risk factor control than CREST2 patients for all measures. There was no significant difference in statin use at baseline, but the mean SAMMPRIS subjects’ LDL was 16.1 mg/dL higher than in CREST2. CREST2 patients had higher rates of use of angiotensin receptor blockers (ARB), calcium channel blockers (CCB), and thiazides, but lower rates of use of angiotensin converting enzyme (ACE) inhibitors. Conclusions: Despite being older, CREST2 patients have significantly better baseline risk factor profiles than SAMMPRIS patients. This could be due to greater appreciation of the importance of risk factor control and healthy lifestyle habits for stroke prevention or more aggressive treatment targets in guideline recommendations. Although risk factor control appears to be improving since SAMMPRIS, many CREST2 patients are still not meeting recommended risk factor goals at baseline and may benefit from IMM protocols.

Prevalence and Outcomes of Undiagnosed Peripheral Arterial Disease Among High Risk Patients in Australia: An Australian REACH Sub-Study

Compared with other manifestations of cardiovascular disease, peripheral arterial disease (PAD) is under-diagnosed. This study aims to investigate the prevalence, risk profile and cardiovascular outcomes of undiagnosed PAD in Australian general practices. A sub-study of the Australian Reduction of Atherothrombosis for Continued Health (REACH) Registry, a prospective cohort study of patients at high risk of atherothrombosis recruited from Australian general practices. Eligible patients for this study had no previous clinical diagnosis of PAD and had an ankle-brachial index (ABI) ≤1.4 at recruitment. Peripheral arterial disease was undiagnosed in 34% Australian REACH participants, 28% patients had low ABI (ABI<0.9) and 11% had intermittent claudication (IC) based on responses to the Edinburgh Claudication Questionnaire (ECQ). We found no significant differences in risk factor control between patient with or without PAD. Intermittent claudication patients had higher risks of non-fatal cardiovascular events and PAD interventions at one year, whereas all-cause mortality rate was higher among patients with ABI<0.9, especially in those who also reported IC. Finally, an ABI<0.9, together with poorly controlled risk factors were independent predictors of incident IC at one year. This study suggests a high rate of undiagnosed PAD among high risk patients in Australian primary health care. These patients are at high risk of events and therefore would potentially benefit from better secondary prevention measures.

Medication Adherence Does Not Explain Black-White Differences in Cardiometabolic Risk Factor Control among Insured Patients with Diabetes

Among patients with diabetes, racial differences in cardiometabolic risk factor control are common. The extent to which differences in medication adherence contribute to such disparities is not known. We examined whether medication adherence, controlling for treatment intensification, could explain differences in risk factor control between black and white patients with diabetes. We identified three cohorts of black and white patients treated with oral medications and who had poor risk factor control at baseline (2009): those with glycated hemoglobin (HbA1c) >8% (n = 37,873), low-density lipoprotein cholesterol (LDL-C) >100mg/dl (n = 27,954), and systolic blood pressure (SBP) >130mm Hg (n = 63,641). Subjects included insured adults with diabetes who were receiving care in one of nine U.S. integrated health systems comprising the SUrveillance, PREvention, and ManagEment of Diabetes Mellitus (SUPREME-DM) consortium. Baseline and follow-up risk factor control, sociodemographic, and clinical characteristics were obtained from electronic health records. Pharmacy-dispensing data were used to estimate medication adherence (i.e., medication refill adherence [MRA]) and treatment intensification (i.e., dose increase or addition of new medication class) between baseline and follow-up. County-level income and educational attainment were estimated via geocoding. Logistic regression models were used to test the association between race and follow-up risk factor control. Models were specified with and without medication adherence to evaluate its role as a mediator. We observed poorer medication adherence among black patients than white patients (p < 0.01): 50.6% of blacks versus 39.7% of whites were not highly adherent (i.e., MRA <80%) to HbA1c oral medication(s); 58.4% of blacks and 46.7% of whites were not highly adherent to lipid medication(s); and 33.4% of blacks and 23.7% of whites were not highly adherent to BP medication(s). Across all cardiometabolic risk factors, blacks were significantly less likely to achieve control (p < 0.01): 41.5% of blacks and 45.8% of whites achieved HbA1c <8%; 52.6% of blacks and 60.8% of whites achieved LDL-C <100; and 45.7% of blacks and 53.6% of whites achieved SBP <130. Adjusting for medication adherence/treatment intensification did not alter these patterns or model fit statistics. Medication adherence failed to explain observed racial differences in the achievement of HbA1c, LDL-C, and SBP control among insured patients with diabetes.

Diabetes and age-related demographic differences in risk factor control

Disparate vascular outcomes in diabetes by race and/or ethnicity may reflect differential risk factor control, especially pre-Medicare. Assess concurrent target attainment for glycohemoglobin <7%, non–high density lipoprotein-cholesterol <130 mg/dL, and blood pressure <140/<90 mm Hg in white, black, and Hispanic diabetics <65 years and ≥65 years of age. The National Health and Nutrition Examination Surveys 1999–2010 data were analyzed on diagnosed and undiagnosed diabetics ≥18 years old. Concurrent target attainment was higher in whites (18.7%) than blacks (13.4% [P = .02] and Hispanics [10.3%, P < .001] <65 years but not ≥65 years of age; 20.0% vs. 15.9% [P = .13], 19.5% [P = .88]). Disparities in health care insurance among younger whites, blacks, and Hispanics, respectively, (87.4% vs. 81.1%, P < .01; 68.0%, P < .001) and infrequent health care (0–1 visits/y; 14.3% vs. 15.0%, P = not significant; 32.0%, P < .001) declined with age. Cholesterol treatment predicted concurrent control in both age groups (multivariable odds ratio >2, P < .001). Risk factor awareness and treatment were lower in Hispanics than whites. When treated, diabetes and hypertension control were greater in whites than blacks or Hispanics. Concurrent risk factor control is low in all diabetics and could improve with greater statin use. Insuring younger adults, especially Hispanic, could raise risk factor awareness and treatment. Improving treatment effectiveness in younger black and Hispanic diabetics could promote equitable risk factor control.

Gender Differences in Cardiovascular Risk Factors in Incident Diabetes

BackgroundCardiovascular disease is a major cause of morbidity and mortality for women and men with diabetes. Previous cross-sectional studies of prevalent diabetes have found that women are less likely to meet American Diabetes Association (ADA) and American Heart Association guidelines for control of cardiovascular risk factors (hemoglobin A1c, low-density lipoprotein [LDL] cholesterol, and blood pressure), but have not studied the critical period immediately after diagnosis. MethodsTo assess gender differences in cardiovascular risk factors at the time of diabetes diagnosis (baseline) and 1 year later (follow-up), we conducted a retrospective cohort study of 6,547 individuals with incident diabetes in an integrated care delivery system. We assessed mean cardiovascular risk factor values by gender and adjusted odds ratios of attaining ADA goals. FindingsCompared with men, at baseline women had lower hemoglobin A1c (7.9% vs. 8.2%; p < .001), higher LDL cholesterol (118.9 vs. 111.5 mg/dL; p < .001), higher systolic blood pressure (131.9 vs. 130.5 mmHg; p < .001), and lower diastolic blood pressure (79.1 vs. 79.7 mmHg; p = .006). At follow-up, the hemoglobin A1c gender gap had closed (6.9% vs. 6.9%; p = .39), and the gender gaps had decreased for blood pressure (129.8/77.0 vs. 128.9/77.6; p = .009) and LDL cholesterol (104.0 vs. 98.2 mg/dL; p < .001). These associations varied by age. Adjusted odds ratios showed similar relationships. ConclusionsIn this cohort of individuals with incident diabetes, men and women had important differences in risk factor control at the time of diabetes diagnosis. These differences varied by age and decreased over time.

Progression of coronary atherosclerosis in African-American patients.

African-Americans with coronary artery disease (CAD) demonstrate worse clinical outcomes than Caucasians. While this is partly due to a lack of accessibility to established therapies, the mechanisms underlying this difference remain to be elucidated. We aimed to characterize the progression of coronary atherosclerosis in African-Americans with CAD. 3,479 patients with CAD underwent serial intravascular ultrasound (IVUS) imaging to evaluate atheroma progression in 7 clinical trials of anti-atherosclerotic therapies. Risk factor control and atheroma progression were compared between African-Americans (n=170) and Caucasians (n=3,309). African-Americans were more likely to be female (51.8% vs. 28.1%, P<0.001), have a higher body mass index (32.8±6.0 vs. 31.3±5.8 kg/m(2), P=0.002) and greater history of hypertension (85.9% vs. 78.8%, P=0.02), diabetes (41.8% vs. 30.6%, P=0.002) and stroke (12.9% vs. 3.0%, P<0.001). Despite a high use of anti-atherosclerotic medications (93% statin, 89% aspirin, 79% β-blocker, 52% ACE inhibitor), African-Americans demonstrated higher levels of LDL-C (2.4±0.7 vs. 2.2±0.7 mmol/L, P=0.006), CRP (2.9 vs. 2.0 mg/dL, P<0.001) and systolic blood pressure (133±15 vs. 129±13 mmHg, P<0.001) at follow-up. There was no significant difference in atheroma volume at baseline (189.0±82.2 vs. 191.6±83.3 mm(3), P=0.82) between two groups. Serial evaluation demonstrated a greater increase in atheroma volume in African-Americans (0.51±2.1 vs. -3.1±1.7 mm(3), P=0.01). This difference persisted with propensity matching accounting for differences in risk factor control (0.1±2.1 vs. -3.7±1.7 mm(3), P=0.02). African-Americans with CAD achieve less optimal risk factor control and greater atheroma progression. These findings support the need for more intensive risk factor modification in African-Americans.

Practice-Linked Online Personal Health Records for Type 2 Diabetes Mellitus

Web-based personal health records (PHRs) have been advocated as a means to improve type 2 diabetes mellitus (DM) care. However, few Web-based systems are linked directly to the electronic medical record (EMR) used by physicians. We randomized 11 primary care practices. Intervention practices received access to a DM-specific PHR that imported clinical and medications data, provided patient-tailored decision support, and enabled the patient to author a "Diabetes Care Plan" for electronic submission to their physician prior to upcoming appointments. Active control practices received a PHR to update and submit family history and health maintenance information. All patients attending these practices were encouraged to sign up for online access. We enrolled 244 patients with DM (37% of the eligible population with registered online access, 4% of the overall population of patients with DM). Study participants were younger (mean age, 56.1 years vs 60.3 years; P < .001) and lived in higher-income neighborhoods (median income, $53,784 vs $49,713; P < .001) but had similar baseline glycemic control compared with nonparticipants. More patients in the intervention arm had their DM treatment regimens adjusted (53% vs 15%; P < .001) compared with active controls. However, there were no significant differences in risk factor control between study arms after 1 year (P = .53). Previsit use of online PHR linked to the EMR increased rates of DM-related medication adjustment. Low rates of online patient account registration and good baseline control among participants limited the intervention's impact on overall risk factor control. clinicaltrials.gov Identifier: NCT00251875.

Sex differences in risk factor control of treated hypertensives: a national primary healthcare-based study in Sweden

To evaluate potential sex differences, this study aimed to investigate blood pressure and lipid control and other risk factors for cardiovascular disease in treated hypertensive (tHT) patients from primary healthcare. This cross-sectional survey of tHT patients was carried out between 2002 and 2005 by 264 primary care physicians from Sweden who consecutively recruited 6537 tHT patients (48% men and 52% women) from medical records. tHT men more often reached the treatment goal for systolic/diastolic blood pressure, less than 140/90 mmHg, than tHT women (30 vs. 26%, P<0.01). Men had lower systolic blood pressure than women, however, women had lower diastolic blood pressure and higher pulse pressure. More tHT women had total cholesterol>or=5.0 mmol/l than corresponding men (75 vs. 64% P<0.001). Men more often had diabetes (25 vs. 20% P<0.001), left ventricular hypertrophy (20 vs. 16% P<0.001), and microalbuminuria (24 vs. 16% P<0.001). Women were more often treated with diuretics (64 vs. 48%) and beta-receptor blockers (54 vs. 51%), and men more often treated with angiotensin-converting enzyme inhibitors (27 vs. 18%), calcium channel blockers (34 vs. 26%), and lipid-lowering drugs (34 vs. 29%). A need still exists for more intensified treatment of elevated blood pressure and hypercholesterolemia, especially in women. In hypertensives of both sexes, smoking and other risk factors also need to be addressed to reduce the risk of cardiovascular disease.

Suboptimal control of glycemia, blood pressure, and LDL cholesterol in overweight adults with diabetes: the Look AHEAD Study

Background The characteristics associated with meeting goals for glycemia, blood pressure (BP), and low-density lipoprotein (LDL) cholesterol for participants with diabetes were examined. Methods Baseline information on demographics, medical history, and anthropometry, as well as on hemoglobin A1c, BP, and LDL cholesterol levels, was measured in 5145 participants of Look AHEAD, a multicenter randomized trial performed to determine whether long-term weight loss and increased physical fitness reduce cardiovascular disease (CVD) in overweight and obese individuals with type 2 diabetes. Logistic regression was used to analyze these cross-sectional data to ascertain associations between participant characteristics and attainment of risk factor goals [hemoglobin A1c <7.0%, BP <130/80 mmHg, and LDL <100 mg/dl]. Results The study population had a mean age of 58.7 years and a mean body mass index of 36.0 kg/m 2. Of the total number of participants, 59.5% were female, 36.8% were of ethnic/racial minority, and 87.3% were on diabetes medications. Upon enrollment, 45.8% had hemoglobin A1c<7.0%, 51.7% had BP<130/80 mmHg, and 37.2% had LDL<100 mg/dl. All three goals were met by only 10.1%. We found consistent evidence for differences in risk factor control by age, gender, race/ethnicity, degree of obesity, education, income, CVD, source of medical care, and medication use. In multivariable analysis, African-American race, increasing degree of obesity, insulin use, and nonutilization of a lipid-lowering agent were associated with not meeting all risk factor goals. Conclusion These data demonstrate that numerous baseline characteristics are associated with suboptimal control of these cardiovascular risk factors among overweight and obese adults with diabetes.

Gender differences and risk factor control in treated hypertensives - a national study in the primary health care of Sweden

The care of treated hypertensive (tHT) patients should aim to optimise the control of risk factors (RF) in order to lower the total cardiovascular (CV) risk. The aim of this cross-sectional survey of tHT from Sweden was to study gender differences in risk factor control from a representative sample in primary health care (PHC). In all, 5397 tHT (48% men), mean age 66 years, were collected from records by 227 GPs from September 2002 to November 2004. Data on individual risk factors were registered from consecutive patients at each centre and stored in a central database. The mean blood pressure was 147/82 mmHg, mean total cholesterol (TC) 5.4 mmol/L, and mean LDL-cholesterol (LDL-C) 3.2 mmol/L. The prevalence of hyperlipidemia (TC >5.0, LDL-C >3.0 mmol/L) was 72% and 67% respectively, left ventricular hypertrophy (LVH) 17%, diabetes 21%, microalbuminuria 21%, and smoking 15%. In all 33% of the tHT were also treated for hyperlipidemia with 40% and 46% fulfilling goal criteria for TC (<5 mmol/l) and LDL-C (<3 mmol/l), respectively. The proportion of all tHT with SBP <140 mmHg was 29% and with DBP<90 mmHg was 74%. A comparison between three different age groups < 56, 56–70, and >70 years showed that females >70 years were older and had a higher SBP, and those >56 years a higher LDL-C than corresponding males. Those had a higher DBP in the age group 56–70 years and also more diabetes, LVH (<70 years) and microalbuminuria than females. More women in the age group <56 years, and more men >70 years smoked. Females were more often treated with thiazide diuretics, and males were more often treated with ACE-inhibitors, calcium channel blockers, and lipid lowering treatment. The CV risk factors associated with tHT were prevalent, especially hyperlipidemia and hypertension in more than two thirds of the patients. Patients with treated hypertension should have a more optimal CV risk factor control in general, including lipid lowering and anti-hypertensive combination therapy. Gender differences in RF control should be minimised.

Gender differences in risk factor control and treatment profile in diabetes: a study in 229 Swedish primary health care centres

Objective To measure the risk factors and treatment profile of diabetes patients treated in primary health care (PHC) in order to evaluate potential gender differences.Design Cross-sectional survey of consecutive diabetes patients.Setting 229 PHC centres in Sweden.Subjects 5082 men and 4293 women with diabetes were investigated (1998–2001).Main outcome measures Glycaemic control (HbA1c), blood pressure, lipid levels, prevalence of left ventricular hypertrophy and microalbuminuria. Proportions of patients with previous ischaemic heart disease (IHD) and specific drug treatment.Results Male patients generally had better blood pressure (<140 and/or 85 mmHg) and glycaemic (HbA1c <6.5%) control than corresponding female patients (44% and 59%, versus 40% and 54% in the 60–75 year age group; p<0.01). Females showed higher levels of total (p<0.01) and HDL cholesterol (p<0.05) than males in all age groups. No gender difference was detected for LDL cholesterol levels in the younger or elderly patients, but in the age group 60–75 years female patients had significantly higher mean LDL cholesterol level than male patients (3.3 vs 3.2 mmol/L; p<0.05). Previously known manifestations of IHD were more common (p<0.01) in male patients.Conclusion Elderly male patients with diabetes had a more favourable risk factor control than corresponding female patients.

Ethnic differences in risk factor control among diabetic hypertensives

Ethnic differences in risk factor control among diabetic hypertensives