Better Control Of Risk Factors Research Articles

Attainment of LDL-cholesterol target in high cardiovascular risk type 1 diabetic French people

As people with type 1 diabetes have increased risk of cardiovascular morbi-mortality, management of cardiovascular risk factors is of crucial importance. We assessed the prevalence and factors associated with LDL-cholesterol (LDL-c) target achievement in patients with type 1 diabetes at high and very-high cardiovascular risk. In this observational multicenter study, we included hospitalized patients with type 1 diabetes who had a fasting blood lipid analysis at admission. Cardiovascular risk level and LDL-c target values were defined according to ESC/EAS guidelines into force at admission: LDL-c target for very-high risk (VHR) and high risk (HR) patients was 1.4 and 1.8 mmol/l respectively for patients included from September 2019 (2019 guidelines) and 1.8 and 2.6 mmol/l respectively for patients included in 2016-2019 (2016 guidelines). LDL-c target attainment was assessed in HR and VHR patients, and factors associated with attainment were identified with multivariable analysis. We included 85 HR patients (median age 37y [interquartile range: 27;45], 64% females) and 356 VHR patients (49 [35;61] years, 42% females). In HR patients, 7% were treated with statins, and 35.3% achieved the LDL-c target. Increasing age (odds ratio 0.58 [95% confidence interval: 0.38;0.89]), body mass index (0.86 [0.75;0.98]), and HbA1c (0.69 [0.50;0.94]) were independently associated with lower odds of attaining LDL-c target. In VHR patients, 36% were treated with statins, and 17.4% achieved LDL-c target. Statin treatment (2.33 [1.22;4.43]), secondary prevention (2.33 [1.21;4.48]) and chronic renal failure (2.82 [1.42;5.61]) were associated with higher odds of attaining LDL-c target. Control of LDL-c is highly insufficient in both HR and VHR patients. Cardiovascular risk evaluation and better control of risk factors may help decrease cardiovascular morbi-mortality in patients with type 1 diabetes. NCT03449784.

Ischemic burden and cardiovascular mortality in 12 middle- and high-income European countries

Abstract Background Death rates from ischemic heart disease (IHD) are consistently higher in middle-income countries (MICs) than in high-income countries (HICs) in Europe, but the reasons are unknown. Purpose The main goal of this study was to disentangle the relation between patient-specific revascularization through percutaneous coronary intervention (PCI) and risk factor burden among European women and men from HICs and MICs Methods We enrolled 22,087 patients with myocardial infarction (MI) from 40 urban hospitals in 12 European countries (6 high-income and 6 middle-income countries; HICs and MICs, respectively) and quantified their traditional risk-factor burden (hypercholesterolemia, diabetes, current smoking and hypertension), the severity of their clinical presentation (incidence of ST-segment elevation MI [STEMI]) and their 30-day cardiovascular outcomes. We calculated women to men risk ratios (RRs) using inverse probability weighting models with estimates compared by interaction test on the log scale. Results Women and men from MICs were significantly (P<0.001) younger than those from HICs. Rates of hypertension and diabetes were significantly (P<0.001) higher in MICs compared to HICs for both women and men. By contrast, we did not find significant differences between country income levels, sex and rates of hypercholesterolemia. In line with these data the use of preventive medications was significantly (P<0.001) more common in MICs than in HICs and in women compared with men. Despite this, the rates of STEMI on hospital presentation were remarkably (P<0.001) higher in MICs than in HICs. (68.8% vs 57.7% in women and 71.0% vs 57.9% in men), and accordingly the case fatality rates for MI were consistently (P<0.001) higher in MICs than in HICs, with women having higher rates of mortality than men (10.3% vs 5.7%; RR: 1.90; 95% CI: 1.67-2.17 and 5.5%, vs 4.2%; RR: 1.31; 95% CI: 1.06-1.63; respectively; P interaction=0.002). Contrary to what was expected, MIC hospitals had higher rates of revascularization procedures than HIC hospitals both in women (72% vs 56%) and men (80% vs 61%). Although the rates of death were consistently lower in the population undergoing revascularization, still mortality remained significantly (P<0.001) higher in MICs than in HICs and in women than in men (6.9% vs 3.8% and 4.3% vs 2.3%; 10.3% vs 5.7%), but the relative RRs for the two country income groups did not significantly differ each other (P interaction=0.40). Conclusions Although the rates of revascularization procedures in MI were higher in MICs, the rates of death were substantially higher in MICs than in HICs. The high burden of risk factors in MICs appears to be the reason of a substantial increased baseline ischemic risk with higher rate of STEMI as MI clinical presentation. Better control of risk factors may mitigate the observed gap in mortality from MI between MICs and HICs, especially in women.

High prevalence of cardiovascular disease and risk factors among type 2 diabetes patients followed in a hospital setting in Portugal: The PICT2RE observational study

Introduction and ObjectivesPortugal is a country with a high prevalence of type 2 diabetes (T2D) and cardiovascular disease (CVD). The prevalence of CVD and cardiovascular (CV) risk factors among T2D patients followed in hospitals in Portugal is not known. The primary objective of this study was to assess the prevalence of CVD and CV risk factors among T2D patients in a hospital setting in Portugal. The clinical management of CVD in the hospital setting was also assessed. MethodsWe performed a non-interventional, multicenter, cross-sectional study with a retrospective phase. T2D patients were consecutively invited to participate. Data were collected retrospectively. ResultsA total of 715 patients were included in the study. Mean age and diabetes duration were 66.6 and 17.4 years, respectively. Of these, 286 patients (40.0%) had been diagnosed with CVD, mostly ischemic heart disease (50.4%). All patients had at least one CV risk factor. CVD was significantly associated with hypertension, hypercholesterolemia, low high-density lipoprotein cholesterol, hypertriglyceridemia and smoking. During the three years prior to study inclusion, the incidence of hyperglycemic episodes and T2D complications increased among patients with established CVD, but the numbers of hospitalization episodes and specialist appointments remained stable. An improvement was observed in key cardiometabolic risk factors. ConclusionsOur study revealed a high prevalence of CVD and CV risk factors among a sample of T2D patients in a hospital setting. Patients with established CVD seem to be adequately managed but further efforts are needed at the prevention stage for better control of risk factors and morbidity.

Discriminative value of pulse wave velocity for arterial stiffness and cardiac injury in prediabetic patients.

Prediabetes (PD) is defined as impaired fasting glucose and/or impaired glucose tolerance (IGT) and may be associated with high risk of cardiovascular injury. It is recommended that PD patients be screened for signs of arterial stiffness and cardiovascular injury to reinforce therapeutic strategies. To identify pulse wave velocity values discriminative for arterial stiffness and cardiovascular injury in PD patients. A cross-sectional study was conducted with PD (N=43) and normoglycemic (N=37) patients who underwent clinical evaluation, arterial stiffness assessment by carotid-femoral pulse wave velocity (cfPWV) using SphygmoCor, laboratory blood analysis, investigation of morphological and functional cardiac variables by transthoracic echocardiogram, and assessment of carotid intima-media-thickness (CIMT) by carotid ultrasonography. A statistical analysis was performed using SPSS software and values of p<0.05 were considered significant. A cfPWV cut-off value of 6.9 m/s was identified for IGT (Sensitivity [SE]: 74% and Specificity [SP]: 51%). Comparison of general data and risk factors between subsets with values above and below this cutoff value revealed higher rates of fasting glucose (p=0.02), obesity (p=0.03), dyslipidemia (p=0.004), early signs of left ventricle (p=0.017) and right ventricle (p=0.03) impaired diastolic function, and elevated CIMT in subjects with cfPWV ≥ 6.9m/s (p=0.04). In PD patients, a cfPWV cutoff of 6.9 m/s was considered a discriminative value for arterial stiffness. These findings highlight the value of early investigation of cardiovascular injury and aggressive therapy strategies with good control of risk factors in PD.

Abstract 13034: Reduction in Cardiovascular Disease Mortality Rates in Brazil is Heterogeneous Across Municipalities: Estimates From the Global Burden of Disease Study, 2000-2018

Introduction: Age-standardized mortality rates (ASMR) for cardiovascular diseases (CVD) decreased in Brazil in the last decades due to better control of risk factors and access to treatment. However, how this reduction distributes across the country’s municipalities is not known, which is important due to the socioeconomic and healthcare disparities in its regions (Northern regions being the most vulnerable) and in municipalities with small vs. large populations. Methods: Ecological study in which the ASMR for CVD were estimated by the Global Burden of Disease (GBD) method for 5,568 Brazilian municipalities from the 5 regions in the triennials: 2000-2002, 2009-2011, and 2016-2018. A visuospatial analysis was applied to create clusters in ASMR with Moran Local analysis. Municipalities were then stratified by population size in &lt;30,000, 30,000-300,000, and &gt;300,000 inhabitants per region, and the % changes in ASMR from 2000-2002 to 2016-2018 were calculated. Results: In 2000-2002, ASMR for CVD were higher in the more developed regions and in the larger municipalities of all regions, except the South. In 2016-2018, CVD ASMR became higher in the least developed Northern regions ( Fig 1 ). Moreover the % reduction in CVD ASMR were lower in small vs. large municipalities within all 5 regions varying from -7% in the small North municipalities to -78% in the large South municipalities. Conclusions: Reduction in CVD mortality in Brazil was lower in the municipalities from the most vulnerable regions and in those with smaller populations. Public policies focusing and tailored to these smaller municipalities, particularly of the least developed regions must be considered a priority.

ACUTE ST-ELEVATION MYOCARDIAL INFARCTION IN OBESE HYPERTENSIVE PATIENTS – CAN WE CONSIDER A DIFFERENT APPROACH?

Objective: Several risk factors, including smoking habits, hypertension, obesity and diabetes, are negatively associated with adverse cardiovascular events. Acute ST-elevation myocardial infarction (STEMI) is a serious problem associated with a high burden of cardiac disease. To determine if obese hypertensive patients had a different clinical presentation and/or a poorer outcome, mainly related to hemorrhagic complications and major adverse cardiovascular events (MACE). Design and method: Retrospective single center cohort study enrolled 121 patients with STEMI diagnosis, admitted to our intensive unit care. In-hospital hemorrhagic complications (IHHC) included intracerebral hemorrhage, resulting in hemodynamic compromise or requiring a blood transfusion were accessed. MACE was a composite endpoint of in-hospital cardiovascular death and sustained ventricular arrhythmic events. Results: The mean age was 58.3 ± 12.7 years and 102 were male (84.3%). Thirty-six patients (29.8%) were overweight and twenty-four (19.8%) were obese. Hypertension was more prevalent in women (84.2% vs. 47.1%, respectively; p 0.003) and also diabetes (42.1% vs. 13.8%, respectively; p 0.021). Obese hypertensive patients were mainly women (52.6% vs. 27.5%; p 0.030). There were no statistically differences in other comorbidities between genders. All obese hypertensive patients were medicated for hypertension, 15 (39.5%) with one drug and 7 (18.4%) with two drugs. The mean systolic blood pressure (SBP) at presentation was 126 ± 2.3 mmHg and diastolic blood pressure was 78.5 ± 1.5 mmHg. Obese hypertensive patients had higher blood pressure values (SBP mean 136 ± 33 mmHg), but no differences in symptoms (p 0.20) or Killip-Kimball classification (p 0.93) were evident. Regarding to in-hospital hemorrhagic complications, females had a statistically significant higher risk (22.2% vs. 7.1%, p 0.045), but it was independent of other comorbidities, including hypertension, obesity or diabetes (r = 0.249; ANOVA p-value &lt; 0.005). In the subset of obese hypertensive patients, no differences in IHHC (p 0.56) or MACE (p 0.18) were detected. Conclusions: Obese hypertensive patients were mainly women medicated with one drug. Despite higher blood pressure values, this group had similar outcomes, including hemorrhagic events. The authors advocate that a good control of risk factors is crucial to minimize their impact on clinical outcomes.

Corneal Confocal Microscopy Identifies People with Type 1 Diabetes with More Rapid Corneal Nerve Fibre Loss and Progression of Neuropathy.

There is a need to accurately identify patients with diabetes at higher risk of developing and progressing diabetic peripheral neuropathy (DPN). Fifty subjects with Type 1 Diabetes Mellitus (T1DM) and sixteen age matched healthy controls underwent detailed neuropathy assessments including symptoms, signs, quantitative sensory testing (QST), nerve conduction studies (NCS), intra epidermal nerve fiber density (IENFD) and corneal confocal microscopy (CCM) at baseline and after 2 years of follow-up. Overall, people with type 1 diabetes mellitus showed no significant change in HbA1c, blood pressure, lipids or neuropathic symptoms, signs, QST, neurophysiology, IENFD and CCM over 2 years. However, a sub-group (n = 11, 22%) referred to as progressors, demonstrated rapid corneal nerve fiber loss (RCNFL) with a reduction in corneal nerve fiber density (CNFD) (p = 0.0006), branch density (CNBD) (p = 0.0002), fiber length (CNFL) (p = 0.0002) and sural (p = 0.04) and peroneal (p = 0.05) nerve conduction velocities, which was not related to a change in HbA1c or cardiovascular risk factors. The majority of people with T1DM and good risk factor control do not show worsening of neuropathy over 2 years. However, CCM identifies a sub-group of people with T1DM who show a more rapid decline in corneal nerve fibers and nerve conduction velocity.

TARGET ACHIEVEMENT IN VERY HIGH RISK PATIENTS IN LIGHT OF THE NEW DYSLIPIDEMIA GUIDELINES

Objective: The 2016 ESC Dyslipidemia guidelines established LDL-cholesterol and HbA1c targets at 70 mg/dl and 7% for patients at very-high cardiovascular risk. The 2019 Dyslipidemia guidelines set LDL-cholesterol targets as low as 55 mg/dl for patients with diabetes, hypertension and atherosclerotic cardiovascular disease (ASCVD) or severe chronic kidney disease (CKD), while maintaining 70 mg/dl targets for patients at high cardiovascular risk. The purpose of our study was to establish a baseline of LDL-cholesterol target achievement based on past years’ experience. Design and method: We performed a retrospective study on patients admitted to our Internal Medicine and Cardiology Department, from January 2014 to December 2018. All patients had arterial hypertension (HTN) and type 2 diabetes mellitus (T2DM). Data regarding patient demographics, comorbidities and laboratory assay results (including glycemia, glycated hemoglobin and a complete lipid profile) were recorded. Data analysis was performed using SPSS version 20. Results: A total of 1239 patients were enrolled with a mean age of 71.3 ± 10.1 years and a slight female predominance (59.4% female). All patients were at very-high risk according to 2016 guidelines, but only 56.3% based on 2019 guidelines: 54.3% had ASCVD and 4.2% had severe CKD. LDL-cholesterol target achievement was 28.6% and 12.4% according to 2016 and 2019 ESC recommendations. The overall mean LDL-cholesterol value was 97.1 ± 39.4 mg/dl, but LDL-cholesterol values were lower after 2016 (93.4 vs. 100.7, p = 0.030) supposedly owing to the publication of the guideline. In terms of HbA1c targets achievement, overall HbA1c was 7.2 ± 1.5% and there was no difference in target achievement before and after 2016: 60.1% vs. 53.8%, p = 0.105. Conclusions: Our study shows that very few patients reach the desired treatment goals but lower targets equal better control of risk factors. We also believe that the timing of guideline publication may have an effect on risk factor correction: yearly publications from the American Diabetes Association may help as a reminder about target HbA1c levels, leading to tighter control.

Booklet handout to improve glycemic control in type-2-DM patients and comparison with other models

Non-adherence is still a major issue in the management of diabetes in Indonesia which leads to complication problems. Medication adherence in diabetes mellitus is related to better glycemic control, better control of risk factors, lower risk of hospitalization, lower health care cost, and lower risk of mortality. Many educational models are applied to achieve the patient's glycemic control. There were two research purposes in this study. The first one was to determine the booklet handout's effectiveness in improving glycemic control in type-2 diabetes mellitus patients in Malaka Jaya Primary Healthcare Centre, Jakarta. The second aim was to compare two different educational models, which were done simultaneously at Pondok Kelapa Primary Healthcare Centre and Duren Sawit Primary Healthcare Centre. A quasi-experimental study design was applied in these prospective studies. A total of 30 patients met the inclusion criteria. The intervention was a booklet handout that was given and presented to the respondent once every month for three months. The parameter used was the A1C (glycated hemoglobin). For patients exposed to booklet handout, 20.0% of them had the A1C level &lt;6.5% initially, then the A1C level &lt;6.5% significantly increased to 73.34% (p=0.005). For patients who were given public counseling, the number of respondents who had the A1C level &lt;6.5% was 16.7%, then the A1C percentage rose to 76.7% (p=0.005). Meanwhile, for patients who were educated with video, the A1C level &lt;6.5% was 6.67% initially, then the A1C level &lt;6.5% increased significantly to 90.0% (p=0.005) in 12 weeks after the intervention. Either booklet handout, public counseling, or video are effective to improve glycemic control in type-2 diabetes mellitus patients.

The risk of micro and macrovascular disease in Egyptian patients with diabetes and peripheral arterial disease

ABSTRACT Aim: The aim of this study was to assess the prevalence of micro- and macrovascular disease in Egyptian patients with diabetes mellitus (DM) and peripheral arterial disease (PAD). Methods: The study included 161 Egyptian patients with DM and PAD (91.3% had type 2 DM and 67.1% were females). Mean diabetes duration was 14.2 ± 5.2 years. Full history, clinical and fundus examination as well as laboratory investigations were done. PAD was diagnosed through assessment of ankle/brachial index (ABI) by Doppler ultrasonography. Results: ABI was <0.9 in 33.5% and >1.3 in 66.5% of patients. A significant positive correlation was found between abnormal ABI and diabetes duration, ischemic heart disease (IHD), diabetic retinopathy and neuropathy, foot ulcers, elevated blood pressure (BP), creatinine, urine albumin/creatinine ratio (ACR) and triglycerides and a significant negative correlation with HDL. Multivariate regression analysis revealed that the independent predictors for PAD in patients with ABI< 0.9 were neuropathy, creatinine, triglyceride, LDL, urine ACR and low HDL, and in patients with ABI >1.3 were IHD, neuropathy, elevated diastolic BP and triglyceride. Conclusion: The risk of micro- and macrovascular disease is high in Egyptian patients with diabetes and PAD. Early diagnosis and good control of risk factors could reduce PAD progression.

Prevalence and risk factors for diabetic neuropathy and painful diabetic neuropathy in primary and secondary healthcare in Qatar.

Aims/IntroductionThis study determined the prevalence and risk factors for diabetic peripheral neuropathy (DPN) and painful DPN (pDPN) in patients with type 2 diabetes in primary healthcare (PHC) and secondary healthcare (SHC) in Qatar.Materials and MethodsThis was a cross‐sectional multicenter study. Adults with type 2 diabetes were randomly enrolled from four PHC centers and two diabetes centers in SHC in Qatar. Participants underwent assessment of clinical and metabolic parameters, DPN and pDPN.ResultsA total of 1,386 individuals with type 2 diabetes (297 from PHC and 1,089 from SHC) were recruited. The prevalence of DPN (14.8% vs 23.9%, P = 0.001) and pDPN (18.1% vs 37.5%, P < 0.0001) was significantly lower in PHC compared with SHC, whereas those with DPN at high risk for diabetic foot ulceration (31.8% vs 40.0%, P = 0.3) was comparable. The prevalence of undiagnosed DPN (79.5% vs 82.3%, P = 0.66) was comparably high, but undiagnosed pDPN (24.1% vs 71.5%, P < 0.0001) was lower in PHC compared with SHC. The odds of DPN and pDPN increased with age and diabetes duration, and DPN increased with poor glycemic control, hyperlipidemia and hypertension, whereas pDPN increased with obesity and reduced physical activity.ConclusionsThe prevalence of DPN and pDPN in type 2 diabetes is lower in PHC compared with SHC, and is attributed to overall better control of risk factors and referral bias due to patients with poorly managed complications being referred to SHC. However, approximately 80% of patients had not been previously diagnosed with DPN in PHC and SHC. Furthermore, we identified a number of modifiable risk factors for PDN and pDPN.

6132Trends in mortality from heart failure between 1980 and 2016

Abstract Background Heart failure (HF) is a highly prevalent disease with high mortality rates worldwide, representing the final stage of a large set of cardiovascular diseases. Purpose To evaluate the trend of mortality rates fromHF, by sex and Brazilian geoeconomic region, between 1980 and 2016. Methods Time series analysis of the underlying causes of death from HF between 1980 and 2016. Population and death-related data were obtained from the Information Technology Department of the Brazilian Unified Health System (DATASUS/MS). Annual crude mortality rates per 100,000 inhabitants were calculated. Standardized rates were estimated according to the age structure of the Brazilian population in the year 2000. Mortality rates were evaluated in all federal units (FedUs) that comprise the Braziliangeoeconomicregions (Northern, Northeastern, Southeastern, Southern and West-Central). Results In Brazil, of the 35,348,374 deaths recorded between 1980 and 2016, 3.2% had HF as the underlying cause. The crude mortality rates from HF in both sexes showed a similar reduction trend over the period. In men, those rates ranged from 13.77 in 1980 to 6.69 per 100,000 inhabitants in 2016, while in women, those rates ranged from 13.15 in 1980 to 7.27 per 100,000 inhabitants in 2016 (Figure 1). Despite the relative stability in the last decade, the standardized rates (Figure 1 - Std) showed a similar trend, but with lower values at the end of the study period. Of all FedUs, only Maranhão (Northeastern region) showed a mortality rate similar to that observed in 1980 (10.44 per 100,000 inhabitants in 1980 and 10.65 per 100,000 inhabitants in 2016). All the other FedUs showed a reduction over the period. The FedUs of the Southeastern, Southern and West-Central regions had the highest reductions, especially Espírito Santo (Southeastern region), Rio Grande do Sul (Southern region) and the Federal District, which decreased from 38.98, 53.34 and 28.56 in 1980 to 3.43, 8.49 and 4.33 per 100,000 inhabitants in 2016, respectively. Figure 1 Conclusions The crude and standardized mortality rates from HF decreased in the last 37 years, probably because of the better control of risk factors and the advances in HF treatment. The most important reductions occurred in the richest regions of the country, which may be related to the improvement of socioeconomic factors.

Inflammation and Vascular Ageing: From Telomeres to Novel Emerging Mechanisms.

Cardiovascular disease (CVD) remains the leading cause of morbility and mortality worldwide. The identification of common cardiovascular risk factors has led to the development of effective treatments that enabled a significant reduction of the global cardiovascular disease burden. However, a significant proportion of cardiovascular risk remains unexplained by these risk factors leaving many individuals at risk of cardiovascular events despite good control of the risk factors. Recent randomized clinical trials and Mendelian randomization studies have suggested that inflammation explains a significant proportion of the residual cardiovascular risk in subjects with good control of risk factors. An accelerated process of vascular ageing is increasingly recognized as a potential mechanism by which inflammation might increase the risk of CVD. In turn, cellular ageing represents an important source of inflammation within the vascular wall, potentially creating a vicious cycle that might promote progression of atherosclerosis, independently from the individual cardiovascular risk factor burden. In this review, we summarise current evidence suggesting a role for biological ageing in CVD and how inflammation might act as a key mediator of this association.

Benefits of Advanced Practice Nursing for Its Expansion in the Spanish Context.

The objective of this study is to describe the impact of the Advanced Practice Nurse role on the clinical practice and patient benefit, as well as to provide reasons for its implementation and expansion in Spain. Through the scoping review method, this study has been carried out according to five thematic blocks: life quality, cost-effectiveness, health results, satisfaction, and accessibility. The critical appraisal was performed with the Critical Appraisal Skills Programme (CASP) tool and the level of evidence and strength of recommendation have been analysed following the Oxford Centre for Evidence-Based Medicine (OCEBM) system. The results show that it is possible to formally implement advanced practice nursing in the Spanish context. The analysis of the Spanish regulatory framework reveals that the generalisation of the Case Manager Nurse is the starting point for the development of advanced practice nursing in Spain. This implementation would have a positive impact on patients in terms of health results, satisfaction, and life quality, given that the advanced practice nurse performs a more effective follow-up of chronic patients with a better control of risk factors, symptoms and health outcomes, and an earlier detection of complications. Considering these results, regional governments should promote the role of the Advanced Practice Nurse to contribute to its expansion.

Epidemiology of Chronic Kidney Disease - Ever More Patients?

Chronic kidney disease (CKD) is a common disorder that often occurs as a complication of other common diseases such as diabetes, obesity, hypertension, or heart failure. Here we review the methodological pitfalls both in measuring kidney function and in determining the epidemiology of kidney disease. CKD is defined as the coincidence of three criteria: A reduced glomerular filtration rate, an anatomical lesion, and a duration of more than three months. Glomerular filtration rate declines with increasing age, but this alone does not constitute kidney disease. In epidemiological studies, exact measurement of glomerular filtration rate is often not feasible. Estimates of glomerular filtration rate depend on serum levels of creatinine or cystatin C, both of which are influenced by extrarenal factors. Anatomical lesion and duration of disease are almost never ascertained in epidemiological studies. Somewhat surprisingly, large-scale statistical modeling by the Global Burden of Disease Study suggests a decline in the world-wide prevalence of CKD in the past decades. In Germany, no longitudinal data is available for lack of a national register. Cross-sectional investigations report prevalences between 6 and 26 percent, depending on age, comorbidities, and geographical region. In the future, better control of risk factors may precede a decline in the incidence of CKD, with prevalences remaining stable due to better medical care and improved survival. In the long run, there is reason to believe that there will not be ever more patients with CKD.

Smartphones and e-tablets in perioperative medicine.

Smartphones and electronic tablets (e-tablets) have become ubiquitous devices. Their ease of use, smartness, accessibility, mobility and connectivity create unique opportunities to improve quality of surgical care from prehabilitation to rehabilitation. Before surgery, digital applications (Apps), serious games and text messaging may help for a better control of risk factors (hypertension, overweight), for smoking cessation, and for optimizing adherence to preoperative recommendations (e.g., regarding anticoagulation or antihypertensive treatments). During surgery, Apps may help to rationalize fluid management and estimate blood loss. After surgery, smartphones and/or connected sensors (pulse oximeter, adhesive path, electronic tattoo, bioimpedance necklace) can be used to monitor body temperature, heart rate, heart rate variability (detection of cardiac arrhythmia), respiratory rate, arterial oxygen saturation and thoracic fluid content. Therefore, these tools have potential for the early detection of infectious, cardiac and respiratory complications in the wards and from home. When connected to echo probes, smartphones and e-tablets can also be used as ultrasound devices during central venous catheter insertion, for peripheral nerve blocks, and to perform echocardiography in patients developing cardiac complications. Finally, electronic checklists now exist as Apps to enhance communication between patients and healthcare professionals, and to track and record step by step each element of the surgical journey. Studies are now urgently needed to investigate whether this digital revolution can translate into a better outcome, an earlier detection of postoperative complications, a decrease in hospital readmissions and in health care costs.

Improvement of survival in Polish stroke patients is related to reduced stroke severity and better control of risk factors: the Krakow Stroke Database.

IntroductionIn the last decade, the stroke mortality rate in Poland significantly decreased. We hypothesised that stroke severity, the major determinant of outcome, is lowered in Polish stroke patients.Material and methodsWe compared the stroke severity in two cohorts of first-ever ischaemic stroke patients admitted within 24 h after stroke onset to the Department of Neurology, Jagiellonian University, Krakow in the years 1994–2000 and 2008–2012. To assess stroke severity we used the National Institute of Health Stroke Scale (NIHSS). We defined mild stroke as an NIHSS score ≤ 4.ResultsWe included 816 patients hospitalised in the years 1994–2000 and 569 patients hospitalised in the years 2008–2012. NIHSS score on admission was higher in the former (mean: 12.0 ±7.0 vs. 8.0 ±6.0, p < 0.01), and the frequency of mild stroke was higher in the latter (12.7% vs. 41.8%, p < 0.01). Although the frequency of hypertension (67.3% vs. 81.2%, p < 0.01), diabetes mellitus (20.8% vs. 26.4%, p = 0.02) and atrial fibrillation (20.7% vs. 26.2%, p = 0.02) was higher in patients hospitalised in the years 2008–2012, the systolic and diastolic blood pressure values and the frequency of fasting hyperglycaemia were lower in this cohort. This cohort also less frequently suffered from hypercholesterolaemia (25.4% vs. 16.3%, p < 0.01).ConclusionsReduced stroke severity is associated with better recognition and control of risk factors and explains the improvement of survival in Polish stroke patients.

Common genetic risk factors for coronary artery disease: new opportunities for prevention?

Atherosclerotic cardiovascular disease (CVD) is a leading cause of mortality and morbidity worldwide, with coronary artery disease (CAD) being the single leading cause of death. Better control of risk factors, enhanced diagnostic techniques and improved medical therapies have all substantially decreased the mortality of CAD in developed countries. However, CAD and other forms of atherosclerotic CVD are projected to remain the leading cause of death by 2030 and we face a number of challenges if the outcomes of CAD are to be further improved. The fact that a substantial fraction of high-risk subjects do not reach treatment goals for important risk factors is one of these challenges. At the same time, there is also a non-negotiable fraction of 'concealed' high-risk subjects who are not detected by current risk algorithms and diagnostic modalities. In recent years, we have started to rapidly increase our knowledge of the framework of common genetics underlying CAD and atherosclerotic CVD in the population. In conjunction with modern diagnostic and therapeutic options, this new genetic knowledge may provide a valuable tool for further improvements in prevention. This review summarizes the recent findings from the search for common genetic risk factors for CAD. Furthermore, the author discusses how such recent findings could potentially be used in a number of clinical applications within CAD prevention, including in clinical risk stratification, in prediction of drug treatment response and in the search for targets for novel preventive therapies.

Abstract W P381: Type and Duration of Exercise in the SAMMPRIS Trial

Background: Previous analyses of SAMMPRIS trial data showed that good risk factor control resulted in a significant reduction in the risk of vascular events (stroke, MI, and vascular death), with exercise as the most important predictor of good outcome. We sought to determine the type and duration of exercise that SAMMPRIS patients reported during the trial. Methods: In SAMMPRIS, 451 patients with recent TIA or stroke attributed to 70-99% intracranial stenosis were randomized to aggressive medical management (AMM) alone or percutaneous transluminal angioplasty and stenting plus AMM at 50 USA sites. AMM included a telephonic lifestyle modification program, INTERVENT, that was provided free of charge to all subjects during their participation in the study. We analyzed self-reported data collected by INTERVENT on the patients’ type and duration of exercise from baseline (n= 394) to 4 years (n=34). We calculated the mean duration for each exercise type at each time period and then compared the change in exercise duration from baseline using paired t-tests and Wilcoxon signed rank tests. Results: Data from subjects who completed the INTERVENT questionnaires were included in these analyses. As shown in the Figure, walking was the most common form of exercise at all time points, as measured by both the duration of exercise and the number of patients performing the exercise. The mean duration of walking and other aerobic activities increased significantly from baseline to all other time points. Conclusions: The type of self-reported exercise performed by SAMMPRIS patients included mostly walking or other aerobic activity and increased significantly during follow-up. Given that exercise was protective against recurrent vascular events, future secondary prevention stroke trials should encourage and monitor exercise participation and neurologists should encourage physical activity in clinical practice.

Adherence to diabetes care

Adherence to diabetes care