Coronary Risk Factor Intervention Research Articles

Pharmacological Undertreatment of Coronary Risk Factors in Patients with Psoriasis: Observational Study of the Danish Nationwide Registries

BackgroundPatients with psoriasis have increased prevalence of coronary risk factors and limited recent results have suggested that these risk factors are undertreated in patients with psoriasis. This may contribute to the increased risk of cardiovascular diseases observed in patients with psoriasis.ObjectiveTo examine the pharmacological treatment of coronary risk factors in patients with severe psoriasis treated with biologic agents in a real-world setting.Methods and FindingsMedical history of patients with severe psoriasis treated with biologic agents in the time period 2007–09 was retrieved from a Danish nationwide registry (DERMBIO). Individual-level linkage of nationwide administrative registries of hospitalizations, concomitant medications, and socioeconomic status was performed to gain insights into the use of pharmacological treatment. A total of 693 patients (mean age 46.1±12.7 years, 65.7% male) with severe psoriasis treated with biologic agents were identified. Hypertension, hypercholesterolemia, and diabetes mellitus were identified in 16.6%, 9.2%, and 6.7% of cases, respectively. Patients with severe psoriasis were significantly less likely to receive cardiovascular pharmacotherapy compared to age, sex, and coronary risk factor matched controls. In psoriatic patients with hypertension 27.7% received no antihypertensive pharmacotherapy. Patients with dyslipidemia received cholesterol-lowering medications in 55.8% of cases and patients with diabetes mellitus received angiotensin converting enzyme inhibitors/angiotensin II receptor blockers and cholesterol-lowering medications in 42.1% and 23.7% of cases, respectively. Similar results were found for the subset of patients with >1 coronary risk factor and for high risk patients with established atherosclerotic disease.ConclusionThis nationwide study of patients with severe psoriasis demonstrated substantial undertreatment of coronary risk factors. Increased focus on identifying cardiovascular risk factors and initiation of preventive cardiovascular pharmacotherapy in patients with psoriasis is warranted.

Secondary Prevention Program: Impact on Cardiovascular Risk

The aims of this study were to determine the effect of a secondary prevention program on the treatment and control of coronary risk factors and to assess whether it improves functional capacity. The study involved 401 patients with coronary heart disease (mean age 57.1 years; 89% men). Clinical and anthropometric data, including blood pressure, were recorded, and electrocardiography, laboratory analysis and exercise testing were performed before and after the program, which lasted 2-3 months. The therapeutic intervention comprised pharmacological treatment of coronary risk factors and the encouragement of life-style changes, including a recommended medically supervised physical exercise regime. By the end of the program, lipid and lipoprotein levels had improved significantly (P< .001 for all). The proportion of smokers decreased from 37.4% to 3.6% (P< .001). Functional capacity increased by 26% (P< .001). In conclusion, patients who took part in the secondary prevention program experienced improvements in cardiovascular risk profile and functional capacity.

Rationale and Design of a Study to Examine Lower Targets for Low-Density Lipoprotein-Cholesterol and Blood Pressure in Coronary Artery Disease Patients The Japanese Coronary Artery Disease Study II (JCADII)

The benefits of coronary risk modification through medication and other methods have been shown in many clinical studies. Recently, aggressive lowering of low-density lipoprotein-cholesterol (LDL-C) has been shown to confer additive benefits in patients with coronary artery disease (CAD). However, it has not been shown in Japanese patients with CAD if multiple aggressive medical interventions for coronary risk factors are beneficial compared with standard regimens, so a prospective, randomized, open-label, blinded-endpoint (PROBE) multicenter study was designed to evaluate whether aggressive lowering of LDL-C and blood pressure in Japanese hypertensive, hypercholesterolemic CAD patients bestows additional benefits compared with regimens based on current Japanese guidelines. Seventeen hospitals in Japan are participating in the Japanese Coronary Artery Disease II (JCADII) study. Hypertensive and hypercholesterolemic patients who have >or=75% stenosis in at least one major coronary artery according to American Heart Association guidelines will be allocated randomly to receive either conventional or aggressive therapy. Standard therapy for hypertension and hypercholesterolemia aims to reduce blood pressure to <140/90 mmHg and LDL-C concentration to <100 mg/dl. Aggressive therapy aims for targets of <120/80 mmHg and <80 mg/dl, respectively. We plan to recruit 500 patients and follow them up for 3 years. Antihypertensive agents, when used, include the angiotensin receptor blockers candesartan and/or losartan. Antihypercholesterolemic agents, when used, include at least one of the following statins: pravastatin, simvastatin, and atorvastatin. The JCADII study will provide important information concerning medical treatment of coronary risk factors in Japanese patients with CAD (UMIN-ID: UMIN000000571).

Morbidity of Myocardial Infarction Multicenter Study in Japan (3M Study)

Although there have been regional studies, there has not been a detailed nationwide investigation of the morbidity from acute myocardial infarction (MI) in Japanese workers. Registration of MI and sudden death was done by full-time occupational physicians in Japan. Among 133,099 workers (109,550 men, 23,549 women) from 41 workplaces (April 1994 to March 1997) and 257,440 workers (207,310 men, 50,130 women) from 76 workplaces (April 1997 to March 2000), 297 fatal and nonfatal cardiac events were registered. The definitions of MI and coronary death followed the criteria of the WHO MONICA Project. The event rate in men rose sharply around the age of 45 years. Using definition 1 (fatal definite + fatal possible + fatal unclassifiable + nonfatal definite), the age-standardized annual event rate and case fatality rate for men aged 35-64 years was 40.2 per 100,000 persons and 22.2%, respectively. These figures were significantly lower compared with those from Western reports and were also lower than previously reported for Japanese communities. The Morbidity of Myocardial Infarction Multicenter Study in Japan revealed a surprisingly low incidence of coronary events, which may be attributable to prevention and early treatment of coronary risk factors among company workers in Japan.

Suboptimal pharmacotherapeutic management of chronic stable angina in the primary care setting

Study Question: Is the treatment and prevention of stable symptomatic angina pectoris by primary care physicians in VA hospital clinics consistent with good medical practice? Methods: A cross-sectional analysis was conducted in 7038 veterans with self-reported coronary heart disease who completed the Seattle Angina Questionnaire (SAQ) and who had made a primary care visit to one of seven VA general internal medicine clinics between May 1997 and January 2000. The main outcome measures included the anginal frequency scale of the SAQ and receipt of prescriptions of appropriate dosing for antianginal medication in three classes (beta-blockers, calcium antagonists, and long-acting nitrates). Effective treatment was defined as a SAQ score of ≥70 representing angina or use of sublingual nitroglycerin ≤2 times per week. Results: Mean age was 66 years, 98% were male, and coded diagnosis included 74% with angina, 51% a previous MI, 45% previous coronary revascularization, 70% hypertension, 27% COPD, and 22% smokers. Seventy percent of the patients with angina by the SAQ were considered adequately treated. Of the 30% of patients with more frequent symptoms, 22% were receiving no antianginal medications and 33% were receiving only one class of antianginal medication. Of the patients with frequent angina who were prescribed medications, 18% were taking no medications at the recommended therapeutic dose and 50% were receiving only one class of antianginal medication at the recommended therapeutic dose. Using multivariate analysis, the presence of CHF, COPD, GERD, joint pains, a previous stroke, and post-traumatic stress disorder were associated with a lower likelihood of successful treatment of angina. There was no difference in treatment outcome by provider type (attending, fellow, resident, PA, NP, etc.). Conclusions: A substantial proportion of patients with frequent episodes of chronic stable angina appeared to be receiving an inadequate antianginal regimen in terms of number of agents and dosages in the VA hospital clinics. Perspective: The Seattle Anginal Questionnaire is a well validated tool for assessing therapeutic interventions in angina. It may not be an appropriate tool for assessing treatment appropriateness in patients without a clinical diagnosis of angina, and in whom concurrent diagnosis may be confused with angina. Nevertheless, it is refreshing that a healthcare system is willing to report the magnitude of undertreatment of cardiovascular symptoms. It would be interesting to assess the relationship between treatment of symptoms and appropriateness of treatment of coronary risk factors. MR

Should Years of Schooling Be Used to Guide Treatment of Coronary Risk Factors?

We wanted to compare the risk of death from coronary heart disease (CHD) for patients of low socioeconomic status, measured by educational level, with established risk factors. We undertook a prospective cohort study. Participants included a representative sample of 6,479 adults aged 25 to 74 years in the United States who were free of CHD at enrollment in the first National Health and Nutrition Examination Survey (NHANES I). Baseline measures included years of education, age, sex, systolic blood pressure, diabetes, total cholesterol level, and smoking. Outcome was death within 10 years from CHD. The relative risk (RR) associated with less than 12 years of education compared with more than 12 years (RR 1.5; 95% confidence interval [CI], 1.2-1.8) was comparable to being male (RR 1.4; 95% CI, 1.2-1.6), smoking (RR 1.4; 95% CI, 1.1-1.6), having a total cholesterol level of greater than 280 mg/dL (RR 1.6; 95% CI, 0.9-2.7), and systolic blood pressure of 130-139 mm Hg (RR 1.6; 95% CI, 1.0-2.4). Findings were comparable for estimates of absolute risk. Low educational level is associated with comparable risk as established risk factors for CHD mortality. Incorporation of educational level into risk-based guidelines for treatment could potentially reduce socioeconomic disparities in CHD by lowering thresholds for treatment.

Audit of primary care angina management in Sandwell, England.

This audit aimed to assess the identification and treatment of coronary risk factors, lifestyle advice given and use of drug therapy, among patients with angina in Sandwell. It was designed to help general practices evaluate their angina management, and highlight areas where practice could be improved. Criteria were based on Sandwell's published angina audit and local clinical guidelines. Each participating practice was asked to identify all patients with angina, from which a 10% sample was randomly selected. The notes of each selected patient were examined for evidence showing whether agreed standards of care had been achieved. Fifteen practices took part, and contributed data on a total of 358 patients. Of patients without contraindications, 66.5% were taking aspirin, 62.1% were prescribed short-acting nitrates and 58.4% were prescribed beta-blockers. Non-white patients were significantly less likely to receive short-acting nitrates (p < 0.001) and women were significantly less likely to receive beta-blockers (p < 0.01). A total of 83.5% of patients had received smoking cessation advice, 75.1% had weight advice, 75.1% were advised about alcohol use and 64.5% about exercise. Overall, 77.4% had a blood pressure check within the previous twelve months, 40.5% had their cholesterol measured and 33.5% had their blood glucose measured. Non-white patients were significantly less likely to receive smoking cessation, weight, exercise and alcohol advice and were less likely to have their blood pressure checked (all p < 0.0001). Patients aged 65 and over were significantly less likely to receive a cholesterol check (p < 0.0001). None of the auditable standards were actually met. This study shows that there is considerable scope to improve the management of angina patients, with particular regard to aspirin. We recommend that practices develop systems to ensure that the appropriate treatment, advice and checks are given to all patients with angina, paying particular attention to those from ethnic minority backgrounds.

Transforming exercise-based cardiac rehabilitation programs into secondary prevention centers: a national imperative.

Transforming exercise-based cardiac rehabilitation programs into secondary prevention centers: a national imperative.

Treatment of coronary risk factors by general practitioners in Austria

Aim of the study was to investigate attitudes and practice of coronary prevention in offices of general practitioners and internists. 67 Austrian physicians took part in a mail survey focussing on hyperlipidemia. 96.6% of participating physicians recommend dietary intervention at least at total cholesterol levels of 250 mg/dl, 98.0% prescribe lipid-lowering drugs at least at total cholesterol levels of 300 mg/dl. At corresponding levels of total/HDL cholesterol ratios and especially at corresponding levels of LDL-cholesterol the proportion was lower. On average 37.9% of physicians spend up to 5 minutes for patients with hyperlipidemia, 10.3% spend more than 15 minutes. The time frame is similar in overweight patients, and bigger in patients with hypertension and diabetes. Dietary therapy is estimated similarly successful in patients with hyperlipidemia and overweight, but estimated more successful in patients with hypertension and diabetes. Drug therapy of hyperlipidemia is estimated more successful than in overweight and diabetes, and worse compared with hypertension. Main measures for improving prevention are more time and specific postgraduate education. The majority of physicians feel that within the last five years quality has improved both in the outpatient and the inpatient care.

Diabetes and Long-Term Survival After Acute Myocardial Infarction:

0027 Some, but not all, recent studies have found that diabetes is independently associated with long-term mortality following hospitalization for acute myocardial infarction. These studies have also failed to control for certain possible confounding factors, such as alcohol use, physical exertion, and socioeconomic status. In the Determinants of Myocardial Infarction Onset Study, trained interviewers performed chart reviews and face-to-face interviews with 1935 patients hospitalized with acute myocardial infarction between 1989 and 1993. We used Cox proportional hazards regression to determine the effect of diabetes on long-term survival after adjustment for sociodemographic characteristics, medical history, and acute infarct-related complications. Of the 1935 patients, 320 (17%) died during a median follow-up of 3.8 years. Diabetes was associated with higher total mortality in adjusted analyses (hazard ratio 1.6; 95% confidence interval, 1.3-2.1). The magnitude of the effect of diabetes was identical to that of a previous myocardial infarction. The effect of diabetes was not significantly modified by age, smoking, household income, use of thrombolytic therapy, type of hypoglycemic treatment, or duration of diagnosed diabetes, but the mortality risk associated with diabetes was higher among women than among men (adjusted hazard ratios 2.8 versus 1.3; p=0.02). In summary, diabetes is independently associated with increased mortality following acute myocardial infarction, particularly among women. The increase in risk is of the same magnitude as a previous myocardial infarction and provides further support for aggressive treatment of coronary risk factors among diabetic patients.

EFFECTS OF EXERCISE AND CARDIAC REHABILITATION ON CARDIOVASCULAR OUTCOMES

Comprehensive cardiac rehabilitation for coronary patients includes a systematic approach to the measurement and treatment of coronary risk factors, along with the better-known exercise training component. Studies of exercise and nutritional interventions in patients with coronary heart disease have documented improved primary outcomes of decreased morbidity and mortality, decreased symptoms, and fewer cardiac rehospitalizations. Quality of life, depression scores, and physical functioning are improved after rehabilitation.

Using a Coronary Risk Score for Screening and Intervention in General Practice

To investigate whether a risk score proposed by the British Regional Heart Study (BRHS), derived from data collected in 1978-1980, provides an appropriate basis for current coronary risk factor screening and intervention in general practice. The BRHS risk score was applied to 1993 men aged 40-59 years and 1353 women aged 35-59 years, from 13 general practices in England, Wales and Scotland, who had health checks during 1991-1992 in the British Family Heart Study (FHS). Modifications to the BRHS risk score were made in order to identify subjects with a current high risk compared with others of the same age and sex. These were validated on 3272 men and 2229 women recruited from different general practices during 1992-1994 in the FHS. Only 9% of men in the FHS fell into the published top (highest risk) quintile of the BRHS score, versus an expected 20%, and 44% fell into the bottom quintile. Scores were, on average, substantially lower in the FHS men than in the BRHS men, principally because of lower measured cholesterol levels (using a Reflotron) and a lower prevalence of cigarette-smoking. The BRHS scores also tended to increase with age, disproportionately identifying older subjects, and were substantially lower in women than in men. Simple age-related modifications to the risk score were therefore devised to overcome these problems. These modifications performed well in the validation. The substantial difference in risk scores between the BRHS and FHS men may reflect both a real reduction in risk and changes in calibration and methodology. Current use of the BRHS risk score may therefore mislead doctors and patients in the direction of complacency. In addition, the published BRHS risk score has an age-dependence that is undesirable in terms of guiding the intensity of lifestyle intervention which should be offered to an individual patient. The simple modifications proposed provide a more appropriate basis for coronary risk factor screening and intervention in general practice, and one that can be used both for men and for women.

Coronary risk factor intervention: Characteristics associated with change

Predicting change in coronary heart disease (CHD) risk factors (cigarette smoking, hypertension, and cholesterol) was undertaken in participants randomized to the treatment group of the Harvard Center of the Multiple Risk Factor Intervention Trial. The predictor variables of interest were psychosocial characteristics, responses to the initial group sessions intervention strategy, and change in weight. The Harvard sample consists of 652 men identified at high risk of death from CHD. Fifty percent were randomized into an intervention group, and 50% were referred to their usual source of medical care. For the analyses, men were stratified by their baseline smoking status and whether they were taking medication for hypertension. The analyses revealed that there was no single model that explained changes in all three risk factors. For example, cigarette smokers were significantly more likely to stop smoking if they attended the group sessions (p less than or equal to .001). An internal locus of control predicted a lower blood pressure by the end of the first year independent of medication (p less than or equal to .05). If a participant entered the trial with serum cholesterol as the only risk factor of concern, attending the group sessions was associated with a significant decrease by the end of the first year (p less than or equal to .05).