Global Risk Reduction Research Articles

Risk Management of Excreta in a Cancer Unit

Although many legal and clinical requirements are in effect for the preparation and administration of the antineoplasic drugs, limited data exist on the potential cytotoxic risk to healthcare personnel from exposure of excreta (urine, feces, expectorations, saliva, perspiration, and vomiting) from patients. A preliminary risk analysis was conducted with a multidisciplinary work group. The objectives were to identify all potential hazards and accidental events that may lead to an accident related to the excreta management and to implement a global risk reduction and quality improvement policy. The findings revealed the potential risks of excreta contamination in health service and led to recommendations for the healthcare team to optimize working conditions, ensure public protection and occupational health, and promote environmental and employee safety.

Cardiometabolic risk reduction through lifestyle intervention programs in the Brazilian public health system

Public health strategies to reduce cardiovascular morbidity and mortality should focus on global cardiometabolic risk reduction. The efficacy of lifestyle changes to prevent type 2 diabetes have been demonstrated, but low-cost interventions to reduce cardiometabolic risk in Latin-America have been rarely reported. Our group developed 2 programs to promote health of high-risk individuals attending a primary care center in Brazil. This study compared the effects of two 9-month lifestyle interventions, one based on medical consultations (traditional) and another with 13 multi-professional group sessions in addition to the medical consultations (intensive) on cardiometabolic parameters. Adults were eligible if they had pre-diabetes (according to the American Diabetes Association) and/or metabolic syndrome (International Diabetes Federation criteria for Latin-America). Data were expressed as means and standard deviations or percentages and compared between groups or testing visits. A p-value < 0.05 was considered significant. Results: 180 individuals agreed to participate (35.0% men, mean age 54.7 ± 12.3 years, 86.1% overweight or obese). 83 were allocated to the traditional and 97 to the intensive program. Both interventions reduced body mass index, waist circumference and tumor necrosis factor-α. Only intensive program reduced 2-hour plasma glucose and blood pressure and increased adiponectin values, but HDL-cholesterol increased only in the traditional. Also, responses to programs were better in intensive compared to traditional program in terms of blood pressure and adiponectin improvements. No new case of diabetes in intensive but 3 cases and one myocardial infarction in traditional program were detected. Both programs induced metabolic improvement in the short-term, but if better results in the intensive are due to higher awareness about risk and self-motivation deserves further investigation. In conclusion, these low-cost interventions are able to minimize cardiometabolic risk factors involved in the progression to type 2 diabetes and/or cardiovascular disease.

The Cardiologist’s Role in the Management of Type 2 Diabetes—A Review

Evidence-based medicine is key to the cardiologist’s role in the management of type 2 diabetes. Proven therapies that reduce cardiovascular (cV) events with few off-target effects are imperative. evidence from epidemiology studies supports the concept that increased blood sugar is correlated with increased cV events. unfortunately, the lowering of glucose with current agents shows limited benefit in reducing cV events. Metformin in the obese individual reduced cV events and is currently first-line therapy in most clinical practice guidelines. recently, a meta-analysis reported that current hypoglycemic agents did not improve cV outcomes and were possibly harmful. Possible exceptions come from the Prospective pioglitazone clinical trial in macrovascular events (Proactive), a secondary prevention trial in patients with prior myocardial infarction in which pioglitazone was found to reduce cV events. glucagon-like peptide-1 (gLP-1) agonists appear to be the most exciting new cV agents, but a dipeptidyl peptidase-4 (DPP4) inhibitor (sitagliptin) combined with a high-dose angiotensin-converting enzyme inhibitor (Acei) (enalapril) may increase blood pressure and heart rate. Lifestyle modification and proven global risk reduction are still the number one ways to reduce cV events in type 2 diabetes.

LDL-cholesterol and the potential for coronary risk improvement: evidence from a practice based carotid Imaging study

Summary Aim: To determine population-attributable predicted coronary risk for major coronary risk factors and derive potential for reduction of global coronary risk. Methods: We obtained images of carotid atherosclerosis in practice-based subjects from self-referred CORDICARE (COR) and physician-referred KARDIOLAB (KAR) patients and calculated 10-year predicted coronary risk according to Swiss guidelines (AGLA) and via reclassification by post-test risk derived from ultrasound-measured total plaque area of the left and right carotid artery. We calculated predicted coronary risk reduction attributable to achievement of all AGLA goals, and for individual risk factors: smokers became nonsmokers, diabetic patients became nondiabetic patients, HDL level, if not already attained, was increased to 1.5 mmol/l, similarly, LDL level was lowered to 1.8 mmol/l, systolic blood pressure (BP) was lowered to 130 and then 10-year risk was recalculated for every subject. Results: COR included N = 900 (48% female), mean age 59 ± 9 years, KAR included N = 600 (35% female), mean age 58 ± 9 years. COR vs KAR: fewer smokers (12% vs 28%), fewer diabetic patients (3% vs 9%), higher systolic BP (133 ± 15 vs 128 ± 19) and higher HDL (1.6 ± 0.4 vs 1.4 ± 0.4 mmol/l), lower AGLA coronary risk (6.6 ± 7.0 vs 8.1 ± 8.6%), lower post-test risk (13.4 ± 14.1 vs 16.2 ± 16.4%). Predicted percent risk reductions for COR and KAR were: all AGLA treatment goals reached (–46% vs –51%), AGLA LDL goals met (–29% vs –29%), LDL ≤1.8 mmol/l (–52% vs –49%), no smokers (–7% vs –12%), HDL 1.50 mmol/l (–13% vs –21%), blood pressure ≤130 (–7% vs –6%), no diabetes (–1% vs –3%).

Persistent dyslipidemia in statin-treated patients. focus on comprehensive lipid management survey in Swiss patients

Statin therapy reduces cardiovascular morbidity and mortality. However, a substantial residual cardiovascular risk can be observed in patients receiving this therapy due to persisting lipid abnormalities as well as to the lack of a systematic global risk-reduction strategy. The objective of the study was to assess the prevalence of dyslipidemia in a cohort of patients living in Switzerland and receiving statin therapy. This cross-sectional study was conducted by 61 primary care physicians, cardiologists, endocrinologists and internists in Switzerland. Patients were consecutive outpatients≥45 years-old, on statin therapy for at least 3 months with available lipid values. A clinical examination and a recording of the latest lipid values on statin therapy were performed in all patients. A total of 473 patients (age 66.3±9.41 years; 61.9% male) were included in the final analysis. Under statin therapy, 40% of the analysed patients had a normal lipid profile, 32.6% presented increased low-density lipoprotein cholesterol (LDL-C) (3.35±0.88 mmol/L), 28.8% low high-density lipoprotein-cholesterol (HDL-C) (0.95±0.18 mmol/L) and 31.1% elevated triglycerides (2.69±1.04 mmol/L). It is of note that the included population was characterised by a high prevalence of cardiovascular risk factors (86.5% patients had 10-year cardiovascular risk>20%). Nevertheless, the lipid lowering therapy was modified in only 15.4% of the patients. Persistent dyslipidemia is a reality in statin-treated patients and may contribute to their residual cardiovascular risk. Therefore, comprehensive lipid management should be preferred to aggressive LDL-C lowering alone. Moreover, strategies to assess and modify the global cardiovascular risk of patients should be taken into account as an important component of primary and secondary prevention.

Clinical evidence of efficacy of red yeast rice and berberine in a large controlled study versus diet

Efficacy of a new patented proprietary combination of natural nutraceuticals (PN) containing natural hypolipidemic as red yeast, policosanol and berberine was tested in a large study on dyslipidemic patients in clinical practice. A parallel, controlled, randomized, multicenter study was designed. After 2 weeks on a stable dietary regimen, the patients were randomized to PN 1 tablet/day associated with diet (PN + D) or diet alone (D) for 16 weeks. Entry criteria were: Tot-Chol >200 mg/dL or LDL-Chol >150 mg/dL without a clear indication for statins, or plasma triglycerides >150 mg/dL. Lipid pattern and CV parameters were evaluated at baseline and monthly. 1,751 patients were enrolled in 248 Italian units, 933 patients on PN + D and 818 on D. The baseline lipid values were: Tot-Chol 255.4 versus 243.1 mg/dL, LDL-Chol 170.1 versus 162.2 mg/dL, HDL-Chol 50.0 versus 48.8 mg/dL, and TG 190.5 versus 184.4 mg/dL. PN constantly and significantly improved lipid parameters versus D group: at 16 weeks −19.1 versus −9.4% for Tot-Chol (p < 0.001), −23.5 versus −10.8% for LDL-Chol (p < 0.001), +11.6 versus +4.0% for HDL-Chol (p < 0.001), −17.9 versus −11.3% for TG (p < 0.001). In conclusions, PN plus diet allows an effective improvement of blood lipids with a significant reduction of global CV risk, suggesting a role for PN in CHD prevention.

What is the best balance of benefits and risks among anti-resorptive therapies for postmenopausal osteoporosis?

Pharmacologic osteoporosis therapy, particularly anti-resorptives, is recommended in postmenopausal women with clinical risk factors for fracture. Treatment decisions should be made based on the relative benefit-risk profile in different patient populations. Emerging options [e.g., selective estrogen receptor modulators (SERMs) and denosumab] may hold promise for providing protection from bone loss and for fracture risk reduction.Osteoporosis, the most common clinical disorder of bone metabolism, is characterized by low bone mineral density, deterioration of microarchitecture, and a consequent increase in bone fragility and risk of fracture. Pharmacologic therapy is recommended in postmenopausal women with clinical risk factors for fracture and includes anti-resorptive agents such as bisphosphonates, hormone therapy, SERMs, and calcitonin. The anabolic agent teriparatide (parathyroid hormone) is usually reserved for high-risk patients or those with glucocorticoid-induced osteoporosis. Strontium ranelate, available outside the USA, has both anti-resorptive and anabolic properties. Supplementation with calcium and vitamin D is recommended for all women aged 50years and older. Bisphosphonates are often considered first-line therapy for osteoporosis and have the largest base of clinical trial data showing efficacy for global fracture risk reduction. Low-dose hormone therapy is appropriate for younger women who are experiencing other menopausal symptoms. In women for whom bisphosphonates are not appropriate or not tolerated or in younger postmenopausal women who have a low risk for hip fracture, SERMs are a suitable treatment option. Calcitonin is designated for patients who are unable or unwilling to tolerate other osteoporosis agents. Emerging options, including newer SERMs (e.g., bazedoxifene and lasofoxifene) and the monoclonal antibody denosumab, may hold promise for providing protection from bone loss and for fracture risk reduction. Because no single agent is appropriate for all patients, treatment decisions should be made on an individual basis, taking into account the relative benefits and risks in different patient populations.

Modern cardiovascular risk management in clinical practice

In this article we address the issue of the continuing growing burden of morbidity and mortality associated to cardiovascular disease, by focusing on how this could be limited by implementing cardiovascular disease prevention strategies. In particular, we propose to: 1) performing a more comprehensive evaluation of total CV risk, especially in patients at high baseline risk profile; 2) achieving a risk reduction through a global therapeutic interventionon the different components of CV risk; 3) improving strategies aimed at global CV risk reduction in future years, especially in patients at high risk, and implementing armonization of guidelines for risk management. The burden of CV disease can be effectively reduced by adopting a more comprehensive approach to identification, risk stratification and treatment of individuals along the cardiovascular continuum.

Denosumab: Anti-RANKL antibody

Denosumab (anti-receptor activator of nuclear factor-kappaB ligand antibody) is a novel agent, a fully human monoclonal antibody that inhibits osteoclastic-medicated bone resorption by binding to osteoblast-produced RANKL. By reducing RANKL binding to the osteoclast receptor RANK, bone resorption and turnover decrease. In phase 2 dose-ranging studies, denosumab had a rapid onset and offset effect. Also, in patients who had received 2 years of denosumab and were discontinued for the third year, rechallenge with denosumab during the fourth year demonstrated a return of responsiveness to denosumab that mimicked the initial treatment. Phase 3 pivotal fracture data were recently presented with positive outcome data; denosumab (60 mg subcutaneously every 6 months) significantly reduced vertebral, nonvertebral, and hip fracture risk compared with placebo, and had an excellent safety profile through 3 years of use. Denosumab will offer a novel approach to managing postmenopausal osteoporosis, one that should be associated with a high adherence rate and global fracture risk reduction.

Goal attainment for multiple cardiovascular risk factors in community‐based clinical practice (a Canadian experience)

The primary goal in the clinical management of atherosclerotic cardiovascular (CV) disease is to reduce major CV risk factors. A single risk factor approach has been traditionally used for demonstrating effectiveness of therapeutic interventions designed to reduce CV risk in clinical trials, but a global CV risk reduction approach should be adopted when assessing effectiveness in the clinical practice setting. To explore combined goal achievement for low-density lipoprotein cholesterol (LDL-C), fasting plasma glucose and systolic-diastolic blood pressure, in patients with dyslipidemia on pharmacotherapy in community-based clinical practices across Canada. In a cross-sectional study, patients filling a prescription for any antihyperlipidemia therapy in selected pharmacies in Ontario, Quebec, British Columbia and Nova Scotia were recruited. Family physicians of the participating patients were requested to provide information from the patient's medical record. Ten-year CV risk was identified for each patient according to the Framingham criteria. High-risk patients comprised 52% of the patient population; 34% were moderate-risk and 14% were low-risk. Patients had a mean of 2.8 CV risk factors; high-risk 3.7, moderate-risk 2.3 and low-risk 1.2. LDL-C goal attainment was observed in 62%, 79% and 96% of patients in high-risk, moderate-risk and low-risk strata respectively. BP goal was achieved in high-risk patients 58%, moderate-risk 83% and low-risk 95%. Glucose levels were below the threshold in 91% of patients. Complete global CV risk reduction was achieved in only 21%, 66% and 92% of high-risk, moderate-risk and low-risk strata respectively. This study illustrates that many patients with dyslipidemia in the Canadian population, and in particular the high-risk patients, did not meet the therapeutic targets for specific CV risk factors according to the Canadian guidelines. Overall, 54% of patients failed to achieve a state of complete global CV risk reduction.

72: The challenge of global risk reduction

72: The challenge of global risk reduction

Does it matter how you lower blood pressure in patients with uncomplicated hypertension? Weighing the evidence

Arterial hypertension is one of the most important preventable causes of death worldwide; therefore, adequate treatment of high blood pressure should be mandatory in each hypertensive patient. Hypertension is now defined on the basis of systolic and diastolic blood pressure levels and classified into stages on the basis of the degree of elevation. Normal blood pressure is widely considered as being less than 120/80 mm Hg. The presence of risk factors such as elevated blood cholesterol, smoking, diabetes, and obesity greatly increases the risk for hypertension-related morbid events. The physiologic link between vascular health and arterial pressure makes it difficult to separate the adverse effects of pressure and vascular functional and structural alterations in determining the adverse complications of hypertension. Several landmark trials in hypertension treatment have been published in the past few years, providing more evidence-based medicine data regarding optimal treatment of hypertension to reduce cardiovascular morbidity and mortality. Maintaining vascular health within the scope of global risk reduction in a personalized manner will be the cornerstone of modern cardiovascular disease prevention rather than waiting until arterial hypertension develops.

Is Metabolic Syndrome the Main Threat to Human Health in the Twenty-First Century?

Series Editor: Marja-Riitta Taskinen See page 2276 Solid evidence has confirmed that the Metabolic Syndrome is associated with an increased risk of both type 2 diabetes and cardiovascular disease (CVD). Recognizing the full blown global epidemics of type 2 diabetes and obesity, the prevalence of the metabolic syndrome is rapidly growing and portends a daunting wave of CVD—a threat to human health in this century. Metabolic syndrome is …

Global Risk Management in Patients with Type 2 Diabetes Mellitus

It is well established that aggressive risk factor modification results in improved cardiovascular disease (CVD) outcomes. Yet, patients with type 2 diabetes mellitus have a much higher baseline risk for cardiovascular events. As type 2 diabetes and hypertension commonly coexist, achieving recommended targets for diabetes, hypertension, and CVD requires aggressive management. Global risk reduction with aggressive low-density lipoprotein reduction and through the additional normalization of glucose levels and blood pressure can help to reduce absolute risk in this very high-risk population.

Weight Management for Type 2 Diabetes Mellitus: Global Cardiovascular Risk Reduction

Most patients with type 2 diabetes mellitus are overweight or obese, and the relation between obesity, especially of the visceral compartment, and the risk for developing diabetes is well recognized. Excessive adipose tissue is associated with insulin resistance as well as the increased expression of proinflammatory cytokines and prothrombotic factors, all of which contribute to elevating the risk for coronary artery disease (CAD). In particular, abdominal obesity, or excess visceral adiposity, has been linked to a cluster of risk factors (high blood pressure, hypertriglyceridemia, low levels of high-density lipoprotein cholesterol, and impaired fasting glucose) that constitute the metabolic syndrome, the presence of which confers an increased risk for type 2 diabetes and cardiovascular disease. In fact, a large waist circumference, a surrogate measure of abdominal adiposity, is 1 of the main criteria for diagnosing the metabolic syndrome. Lifestyle modification is the first-line approach to the management of obesity and the metabolic syndrome. However, if patients are unable to achieve a weight loss of 5%-10% of initial body weight and improve cardiometabolic risk factors with lifestyle modification alone, physicians should consider using adjunctive long-term pharmacotherapy. A variety of approved and investigational pharmacologic agents, including sibutramine, orlistat, metformin, and rimonabant, have been shown to reduce weight and ameliorate metabolic syndrome components, thereby reducing cardiovascular risk. Such global risk reduction is crucial for patients with diabetes, in whom CAD is a major cause of mortality.

Diabetic Endovascular Disease: Role of Coronary Artery Revascularization

This century brings a pandemic of diabetes mellitus, with marked increases in early-accelerated atherosclerosis. When asymptomatic patients with diabetes present for evaluation, they have more extensive coronary atherosclerosis, lower ejection fractions, higher rates of previous cardiac events, and more silent ischemia than the normal population. The challenge faced by clinicians is to accurately identify asymptomatic patients with diabetes who have significant coronary ischemia that would benefit from revascularization. Diabetic endovascular disease has all the high-risk features to promote atherosclerosis and coronary occlusion: hyperglycemia-induced endothelial dysfunction, impaired fibrinolysis, increased platelet aggregation, plaque instability, dysfunctional arterial remodeling, and fibrotic and calcified coronary arteries. The optimal revascularization strategy for patients with diabetes is an ongoing debate. The advent of drug-eluting stents has changed the landscape, and some have suggested that the current role of coronary artery bypass grafting may be reduced by as much as 46%. Unfortunately, there is limited evidence from randomized, controlled trials that reflects current practice and could guide clinicians in making the best choices for patients with diabetes and coronary disease. It is hoped that ongoing trials--including Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D), Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM), and Coronary Artery Revascularisation in Diabetes (CARDia)--will answer many of the remaining questions. Still, the best treatment includes lifestyle modification and early prevention strategies with global risk reduction.

Reduction of global cardiovascular risk with nutritional versus nutritional plus physical activity intervention in Colombian adults

Cardiovascular disease is a major cause of morbidity/mortality in non-developed countries. Reports of the effects of non-pharmacological interventions on global cardiovascular risk in Latin American adults, however, are scarce. To compare the change in global cardiovascular risk induced by a tailored, Adult Treatment Panel-III compliant nutrition program versus the same program with addition of supervised, regular physical activity in Colombian adults. The study was a randomized, controlled trial. Seventy-five Colombian patients aged 40-70 years and with Framingham-estimated global cardiovascular risk of 1% or higher were randomly assigned to a nutritional intervention program or a combined nutritional intervention-physical exercise program for 16 weeks. Patients underwent medical and anthropometric evaluation, bioelectrical impedance, lipid profile and Framingham global cardiovascular risk determination at baseline and at the end of follow-up. The groups were comparable at baseline; 21 persons in the nutritional intervention program group and 27 in the nutritional intervention-physical exercise program group completed the follow-up. Global cardiovascular risk modification (mean+/-SE) was -2.04+/-1.1 absolute percentage points (relative reduction 19.6%) in the nutritional intervention-physical exercise program group, compared with 0.23+/-0.9 (relative increase 2.8%) in the nutritional intervention program group. Mean difference in global cardiovascular risk modification between groups reached borderline statistical significance in ANCOVA (P=0.054). Reductions in systolic and diastolic blood pressure, waist circumference and low-density lipoprotein cholesterol were similar, but the nutritional intervention-physical exercise program group achieved significantly greater improvements in body weight, body mass index, percentage body fat and high-density lipoprotein cholesterol. Our data suggest that a structured nutritional intervention-physical exercise program is more efficacious than a nutritional intervention program in the reduction of global cardiovascular risk and cardiovascular risk factors, in only 16 weeks.

Hypertriglyceridemia—why, when and how should it be treated?

The relationship between serum triglyceride levels and cardiovascular disease has remained enigmatic despite four decades of research. The majority of the available evidence tends to support the role of hypertriglyceridemia as an independent risk factor for cardiovascular disease. However, there are no guidelines recommending a target triglyceride level for prevention of cardiovascular disease. The focus of lipid lowering therapy still remains the reduction of global cardiovascular risk by optimizing LDL cholesterol levels. Therapeutic options for triglyceride-lowering include lifestyle modification and pharmacological agents, such as fibrates, omega 3 fatty acids and niacin. Post-hoc analyses of the Helsinki Heart Study, Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial and Bezafibrate Infarction Prevention Study suggest a beneficial effect of the treatment of hypertriglyceridemia with fibrates, mainly in obese subjects with insulin resistance. However, in order to establish the actual clinical relevance of lowering triglyceride levels, prospective trials need to be conducted with the specific purpose of studying the effects of triglyceride reduction on clinical end points, i. e. coronary events and stroke.

Short and longer term outcomes of a diabetes disease management program in underserved Latino patients

ABSTRACTObjective: We developed a Diabetes Management Program (DMP) located within a county health center for poor, primarily Latino patients. The purpose of this study is to document if our program can achieve global risk reduction in our population, and whether or not this improvement can be sustained through on-going follow-up in primary care.Research design and methods: This is an observational study, using a database into which patient information is entered weekly. Information from the database is used to compare patients at baseline, at discharge from the program and then after a year or more of follow-up in primary care.Main outcomes measures: Change in A1C, low density lipoprotein (LDL) cholesterol, blood pressure (BP) levels; use of cardiovascular disease (CVD) modifying medications.Results: 171 patients had data available at baseline, discharge and annual follow-up. Baseline A1C is 8.5 ± 1.9% (mean ± SD), with a fall to 7.4 ± 1.2% ( p < 0.001) at discharge. After 1 year in primary care the A1C increased back to baseline (8.3 ± 1.7%), without change in diabetes medications. LDL cholesterol and BP levels are reduced by discharge, and these improvements persisted at the annual follow-up. Additionally, patients continued with CVD risk modifying therapy (statins, angiotensin converting enzyme inhibitors/angiotensin receptor blockers, aspirin) at their annual visits. Limitations to this study include the small number of patients who returned for their annual examination, the lack of a matched control group for comparison and the use of an existing database.Conclusions: Persistent change in CVD risk factors can be made through diabetes disease management; changes in glucose control, however, are more difficult to sustain in spite of continued use of medication. Further research must be undertaken to help improve glycemic outcomes over time.

Isolated low high density lipoprotein-cholesterol (HDL-C): implications of global risk reduction. Case report and systematic scientific review

BackgroundThe importance of low high-density lipoprotein cholesterol (HDL-C), elevated non HDL-C (as part of the metabolic syndrome, prediabetes, and type 2 diabetes mellitus), and an isolated low HDL-C is rapidly emerging. The antiatherosclerotic roles of reverse cholesterol transport and the pleiotropic antioxidant – anti-inflammatory mechanistic effects of HDL-C are undergoing rapid exponential growth.Case presentationIn 1997 a 53-year-old Caucasian male presented with a lipoprotein profile of many years duration with an isolated low HDL-C and uric acid levels in the upper quintile of normal. He developed an acute myocardial infarction involving the right coronary artery and had percutaneous transluminal coronary angioplasty with stenting of this lesion. He also demonstrated a non-critical non-flow limiting lesion of the proximal left anterior descending coronary artery at the time of this evaluation.Following a program of global risk reduction this patient has done well over the past 7 years and remains free of any clinical signs and symptoms of atherosclerosis. His HDL-C and uric acid levels are currently in the normal physiological range.ConclusionLow HDL-C and isolated low HDL-C constitute an important risk factor for atherosclerosis. Therapies that lead to a return to normal physiologic range of HDL-C may result in the delay of atherosclerotic progression.