Latest from Heart

CHADS2 and CHA2DS2-VASc score to assess risk of stroke and death in patients paced for sick sinus syndrome

Sat, 15 Jun 2013 00:00:00 +0000

ObjectiveThe risk of stroke in patients with atrial fibrillation (AF) can be assessed by use of the CHADS2 and the CHA2DS2-VASc score system. We hypothesised that these risk scores and their individual components could also be applied to patients paced for sick sinus syndrome (SSS) to evaluate risk of stroke and death. DesignProspective cohort study. SettingsAll Danish pacemaker centres and selected centres in the UK and Canada. PatientsRisk factors were recorded prior to pacemaker implantation in 1415 patients with SSS participating in the Danish Multicenter Randomized Trial on Single Lead Atrial Pacing versus Dual Chamber Pacing in Sick Sinus Syndrome (Danpace) trial. Development of stroke was assessed at follow-up visits and by evaluation of patient charts. Mortality was assessed from the civil registration system. InterventionsPatients were randomised to AAIR (N=707) or DDDR pacing (N=708). Main outcome measuresStroke and death during follow-up. ResultsMean follow-up was 4.3{+/-}2.5 years. In the AAIR group 6.9% patients developed stroke versus 6.1% in the DDDR group (NS). There was a significant association between CHADS2 score and the development of stroke (HR 1.41; 95% CI 1.22 to 1.64, p<0.001). CHA2DS2-VASc score was also significantly associated with stroke (HR 1.25; CI 1.12 to 1.40, p<0.001). CHADS2 score (HR 1.46; CI 1.36 to 1.56, p<0.001) and CHA2DS2-VASc score (HR 1.39; CI 1.31 to 1.46, p<0.001) were associated with mortality. Results were still significant after adjusting for AF and anticoagulation therapy. ConclusionsCHADS2 and CHA2DS2-VASc score are associated with increased risk of stroke and death in patients paced for SSS irrespective of the presence of AF.

Elevated resting heart rate, physical fitness and all-cause mortality: a 16-year follow-up in the Copenhagen Male Study

Sat, 15 Jun 2013 00:00:00 +0000

ObjectiveTo examine whether elevated resting heart rate (RHR) is an independent risk factor for mortality or a mere marker of physical fitness (VO2Max). MethodsThis was a prospective cohort study: the Copenhagen Male Study, a longitudinal study of healthy middle-aged employed men. Subjects with sinus rhythm and without known cardiovascular disease or diabetes were included. RHR was assessed from a resting ECG at study visit in 1985-1986. VO2Max was determined by the Astrand bicycle ergometer test in 1970-1971. Subjects were classified into categories according to level of RHR. Associations with mortality were studied in multivariate Cox models adjusted for physical fitness, leisure-time physical activity and conventional cardiovascular risk factors. Results2798 subjects were followed for 16 years. 1082 deaths occurred. RHR was inversely related to physical fitness (p<0.001). Overall, increasing RHR was highly associated with mortality in a graded manner after adjusting for physical fitness, leisure-time physical activity and other cardiovascular risk factors. Compared to men with RHR [≤]50, those with RHR >90 had an HR (95% CI) of 3.06 (1.97 to 4.75). With RHR as a continuous variable, risk of mortality increased with 16% (10-22) per 10 beats per minute (bpm). There was a borderline interaction with smoking (p=0.07); risk per 10 bpm increase in RHR was 20% (12-27) in smokers, and 14% (4-24) in non-smokers. ConclusionsElevated RHR is a risk factor for mortality independent of physical fitness, leisure-time physical activity and other major cardiovascular risk factors.

Experiences of patients and professionals participating in the HITS home blood pressure telemonitoring trial: a qualitative study [RESEARCH]

Thu, 23 May 2013 00:00:00 +0000

ObjectivesTo explore the experiences of patients and professionals taking part in a randomised controlled trial (RCT) of remote blood pressure (BP) telemonitoring supported by primary care. To identify factors facilitating or hindering the effectiveness of the intervention and those likely to influence its potential translation to routine practice. DesignQualitative study adopting a qualitative descriptive approach. Participants25 patients, 11 nurses and 9 doctors who were participating in an RCT of BP telemonitoring. A maximum variation sample of patients from within the trial based on age, sex and deprivation status of the practice was sought. Setting6 primary care practices in Scotland. MethodData were collected via taped semistructured interviews. Initial thematic analysis was inductive. Multiple strategies were employed to ensure that the analysis was credible and trustworthy. ResultsPrior to the trial, both patients and professionals were reluctant to increase the medication based on single BP measurements taken in the surgery. BP measurements based on multiple electronic readings were perceived as more accurate as a basis for action. Patients using telemonitoring became more engaged in the clinical management of their condition. Professionals reported that telemonitoring challenged existing roles and work practices and increased workload. Lack of integration of telemonitoring data with the electronic health record was perceived as a drawback. ConclusionsBP telemonitoring in a usual care setting can provide a trusted basis for medication management and improved BP control. It increases patients' engagement in the management of their condition, but supporting telemetry and greater patient engagement can increase professional workloads and demand changes in service organisation. Successful service design in practice would have to take account of how additional roles and responsibilities could be realigned with existing work and data management practices. The embedded qualitative study was included in the protocol for the HITS trial registered with ISRCTN no. 72614272.

Telemonitoring-based service redesign for the management of uncontrolled hypertension (HITS): cost and cost-effectiveness analysis of a randomised controlled trial [RESEARCH]

Thu, 23 May 2013 00:00:00 +0000

ObjectivesTo compare the costs and cost-effectiveness of managing patients with uncontrolled blood pressure (BP) using telemonitoring versus usual care from the perspective of the National Health Service (NHS). DesignWithin trial post hoc economic evaluation of data from a pragmatic randomised controlled trial using an intention-to-treat approach. Setting20 socioeconomically diverse general practices in Lothian, Scotland. Participants401 primary care patients aged 29-95 with uncontrolled daytime ambulatory blood pressure (ABP) ([≥]135/85, but <210/135 mm Hg). InterventionParticipants were centrally randomised to 6 months of a telemonitoring service comprising of self-monitoring of BP transmitted to a secure website for review by the attending nurse/doctor and patient, with optional automated patient decision-support by text/email (n=200) or usual care (n-201). Randomisation was undertaken with minimisation for age, sex, family practice, use of three or more hypertension drugs and self-monitoring history. Main outcome measuresMean difference in total NHS costs between trial arms and blinded assessment of mean cost per 1 mm Hg systolic BP point reduced. ResultsHome telemonitoring of BP costs significantly more than usual care (mean difference per patient {pound}115.32 (95% CI {pound}83.49 to {pound}146.63; p<0.001)). Increased costs were due to telemonitoring service costs, patient training and additional general practitioner and nurse consultations. The mean cost of systolic BP reduction was {pound}25.56/mm Hg (95% CI {pound}16.06 to {pound}46.89) per patient. ConclusionsOver the 6-month trial period, supported telemonitoring was more effective at reducing BP than usual care but also more expensive. If clinical gains are maintained, these additional costs would be very likely to be compensated for by reductions in the cost of future cardiovascular events. Longer-term modelling of costs and outcomes is required to fully examine the cost-effectiveness implications. Trial registrationInternational Standard Randomised Controlled Trials, number ISRCTN72614272.

Effects of train noise and vibration on human heart rate during sleep: an experimental study [RESEARCH]

Thu, 23 May 2013 00:00:00 +0000

ObjectivesTransportation of goods on railways is increasing and the majority of the increased numbers of freight trains run during the night. Transportation noise has adverse effects on sleep structure, affects the heart rate (HR) during sleep and may be linked to cardiovascular disease. Freight trains also generate vibration and little is known regarding the impact of vibration on human sleep. A laboratory study was conducted to examine how a realistic nocturnal railway traffic scenario influences HR during sleep. DesignCase-control. SettingHealthy participants. Participants24 healthy volunteers (11 men, 13 women, 19-28 years) spent six consecutive nights in the sleep laboratory. InterventionsAll participants slept during one habituation night, one control and four experimental nights in which train noise and vibration were reproduced. In the experimental nights, 20 or 36 trains with low-vibration or high-vibration characteristics were presented. Primary and secondary outcome measuresPolysomnographical data and ECG were recorded. ResultsThe train exposure led to a significant change of HR within 1 min of exposure onset (p=0.002), characterised by an initial and a delayed increase of HR. The high-vibration condition provoked an average increase of at least 3 bpm per train in 79% of the participants. Cardiac responses were in general higher in the high-vibration condition than in the low-vibration condition (p=0.006). No significant effect of noise sensitivity and gender was revealed, although there was a tendency for men to exhibit stronger HR acceleration than women. ConclusionsFreight trains provoke HR accelerations during sleep, and the vibration characteristics of the trains are of special importance. In the long term, this may affect cardiovascular functioning of persons living close to railways.

INterpreting the Processes of the UMPIRE Trial (INPUT): protocol for a qualitative process evaluation study of a fixed-dose combination (FDC) strategy to improve adherence to cardiovascular medications [PROTOCOL]

Thu, 23 May 2013 00:00:00 +0000

IntroductionThis paper describes a planned process evaluation of the Use of a Multidrug Pill In Reducing Cardiovascular Events (UMPIRE) trial, one of several randomised clinical trials taking place globally to assess the potential of cardiovascular drugs as a fixed-dose combination (polypill) in cardiovascular disease prevention. A fixed-dose combination may be a promising strategy for promoting adherence to medication; alleviating pill burden through simplifying regimens and reducing cost. This process evaluation will complement the UMPIRE trial by using qualitative research methods to inform understanding of the complex interplay of factors that underpin trial outcomes. MethodsA series of semistructured, in-depth interviews with local health professionals and UMPIRE trial participants in India and the UK will be undertaken. The aim is to understand their views and experiences of the trial context and of day-to-day use of medications more generally. The grounded theory approach will be used to analyse data and help inform the processes of the UMPIRE trial. Ethics and disseminationThe study has received ethical approval for all sites in the UK and India where trial participant interviews will be undertaken. The process evaluation will help inform and enhance the understanding of the UMPIRE trial results and its applicability to clinical practice as well as shaping policy regarding strategies for improving cardiovascular medication adherence.

Congenital heart disease and rheumatic heart disease in Africa: recent advances and current priorities

Thu, 16 May 2013 00:00:00 +0000

Africa has one of the highest prevalence of heart diseases in children and young adults, including congenital heart disease (CHD) and rheumatic heart disease (RHD). We present here an extensive review of recent data from the African continent highlighting key studies and information regarding progress in CHD and RHD since 2005. Main findings include evidence that the CHD burden is underestimated mainly due to the poor outcome of African children with CHD. The interest in primary prevention for RHD has been recently re-emphasised, and new data are available regarding echocardiographic screening for subclinical RHD and initiation of secondary prevention. There is an urgent need for comprehensive service frameworks to improve access and level of care and services for patients, educational programmes to reinforce the importance of prevention and early diagnosis and a relevant research agenda focusing on the African context.

Cardiovascular disease risk scores in identifying future frailty: the Whitehall II prospective cohort study

Wed, 15 May 2013 00:00:00 +0000

ObjectivesTo examine the capacity of existing cardiovascular disease (CVD) risk algorithms widely used in primary care, to predict frailty. DesignProspective cohort study. Risk algorithms at baseline (1997-1999) were the Framingham CVD, coronary heart disease and stroke risk scores, and the Systematic Coronary Risk Evaluation. SettingCivil Service departments in London, UK. Participants3895 participants (73% men) aged 45-69 years and free of CVD at baseline. Main outcome measureStatus of frailty at the end of follow-up (2007-2009), based on the following indicators: self-reported exhaustion, low physical activity, slow walking speed, low grip strength and weight loss. ResultsAt the end of the follow-up, 2.8% (n=108) of the sample was classified as frail. All four CVD risk scores were associated with future risk of developing frailty, with ORs per one SD increment in the score ranging from 1.35 (95% CI 1.21 to 1.51) for the Framingham stroke score to 1.42 (1.23 to 1.62) for the Framingham CVD score. These associations remained after excluding incident CVD cases. For comparison, the corresponding ORs for the risk scores and incident cardiovascular events varied between 1.36 (1.15 to 1.61) and 1.64 (1.50 to 1.80) depending on the risk algorithm. ConclusionsThe use of CVD risk scores in clinical practice may also have utility for frailty prediction.

Cardiac arrest management in general practice in Ireland: a 5-year cross-sectional study [RESEARCH]

Tue, 14 May 2013 00:00:00 +0000

ObjectiveTo document the involvement of general practitioners (GPs) in cardiac arrests with resuscitation attempts (CARAs) and to describe the outcomes. DesignA 5-year prospective cross-sectional study of GPs in Ireland equipped with automated external defibrillators (AEDs) and immediate care training by the MERIT Project, with data collection every 3 months over the 5-year period. Practices reported CARAs by quarterly survey with an 89% mean response rate (81-97% for the period). SettingGeneral practices throughout Ireland. Participants495 GP participated: 168 (33.9%) urban, 163 (32.9%) rural and 164 (33.1%) mixed. InterventionsAll participating practices received a standard AED and basic life support kit. Training in immediate care was provided for at least one GP in the practice. Main outcome measuresIncidence of CARA in participating practices. Return of spontaneous circulation (ROSC) and discharge alive from hospital. Results36% of practices were involved in a CARA during the 5-year period and 13% were involved in more than one CARA. Of the 272 CARAs reported, ROSC occurred in 32% (87/272) and discharge from hospital in 18.7% (49/262). In 45% of cases, the first AED was brought by the GP and in 65%, the GP arrived before the ambulance service. More cases occurred in rural and mixed settings than urban ones, but the survival rates did not differ between areas. In 65% of cases, the GP was on duty at the time of the incident and 47% of cases occurred in the patient's home. ConclusionsThese outcomes are comparable with more highly structured components of the emergency response system and indicate that GPs have an important role to play in the care of patients in their own communities. GPs experience cardiac arrest cases during the course of their daily work and provide prompt care which results in successful outcomes in urban, mixed and rural settings.

Differences in drug utilisation between men and women: a cross-sectional analysis of all dispensed drugs in Sweden [RESEARCH]

Fri, 3 May 2013 00:00:00 +0000

ObjectivesAscertain the extent of differences between men and women in dispensed drugs since there is a lack of comprehensive overviews on sex differences in the use of prescription drugs. DesignCross-sectional population database analysis. MethodsData on all dispensed drugs in 2010 to the entire Swedish population (9.3 million inhabitants) were obtained from the Swedish Prescribed Drug Register. All pharmacological groups with ambulatory care prescribing accounting for >75% of the total volume in Defined Daily Doses and a prevalence of >1% were included in the analysis. Crude and age-adjusted differences in prevalence and incidence were calculated as risk ratios (RRs) of women/men. ResultsIn all, 2.8 million men (59%) and 3.6 million women (76%) were dispensed at least one prescribed drug during 2010. Women were dispensed more drugs in all age groups except among children under the age of 10. The largest sex difference in prevalence in absolute numbers was found for antibiotics that were more common in women, 265.5 patients (PAT)/1000 women and 191.3 PAT/1000 men, respectively. This was followed by thyroid therapy (65.7 PAT/1000 women and 13.1 PAT/1000 men) and antidepressants (106.6 PAT/1000 women and 55.4 PAT/1000 men). Age-adjusted relative sex differences in prevalence were found in 48 of the 50 identified pharmacological groups. The pharmacological groups with the largest relative differences of dispensed drugs were systemic antimycotics (RR 6.6 CI 6.4 to 6.7), drugs for osteoporosis (RR 4.9 CI 4.9 to 5.0) and thyroid therapy (RR 4.5 CI 4.4 to 4.5), which were dispensed to women to a higher degree. Antigout agents (RR 0.4 CI 0.4 to 0.4), psychostimulants (RR 0.6 CI 0.6 to 0.6) and ACE inhibitors (RR 0.7 CI 0.7 to 0.7) were dispensed to men to a larger proportion. ConclusionsSubstantial differences in the prevalence and incidence of dispensed drugs were found between men and women. Some differences may be rational and desirable and related to differences between the sexes in the incidence or prevalence of disease or by biological differences. Other differences are more difficult to explain on medical grounds and may indicate unequal treatment.

Dabigatran use in Danish atrial fibrillation patients in 2011: a nationwide study [RESEARCH]

Fri, 3 May 2013 00:00:00 +0000

ObjectiveDabigatran was recently approved for anticoagulation in patients with atrial fibrillation (AF); data regarding real-world use, comparative effectiveness and safety are sparse. DesignPharmacoepidemiological cohort study. Methods/settingsFrom nationwide registers, we identified patients with an in-hospital or outpatient-clinic AF diagnosis who claimed a prescription of dabigatran 110 or 150 mg, or vitamin K antagonist (VKA), between 22 August and 31 December 2011. HRs of thromboembolic events (ischaemic stroke, transitory ischaemic attack and peripheral artery embolism) and bleedings were estimated using Cox regression analyses in all patients and stratified by previous VKA use. ResultsOverall, 1612 (3.1%) and 1114 (2.1%) patients claimed a prescription of dabigatran 110 and 150 mg, and 49640 (94.8%) of VKA. Patients treated with dabigatran 150 mg were younger with less comorbidity than those treated with dabigatran 110 mg and VKA, as were VKA naive patients compared with previous VKA users. Recommendations set by the European Medicine Agency (EMA) for dabigatran were met in 90.3% and 55.5% of patients treated with 110 and 150 mg. Patients treated with 150 mg dabigatran, who did not fulfil the recommendations by EMA, were >80 years, patients with liver or kidney disease, patients with previous bleeding. Compared with VKA, the thromboembolic risk associated with dabigatran 110 and 150 mg was HR 3.52 (1.40 to 8.84) and 5.79 (1.81 to 18.56) in previous VKA users, and HR 0.95(0.47 to 1.91) and 1.14(0.60 to 2.16) in VKA naive patients. Bleeding risk was increased in previous VKA users receiving dabigatran 110 mg, but not in patients with 150 mg dabigatran, nor in the VKA naive users. ConclusionsDeviations from the recommended use of dabigatran were frequent among patients treated with 150 mg. With cautious interpretation, dabigatran use in VKA naive patients seems safe. Increased risk of thromboembolism and bleeding with dabigatran among previous VKA users was unexpected and may reflect patient selection and drug switching' practices.

Influenza-like illness in acute myocardial infarction patients during the winter wave of the influenza A H1N1 pandemic in London: a case-control study [RESEARCH]

Thu, 2 May 2013 00:00:00 +0000

ObjectiveTo investigate recent respiratory and influenza-like illnesses (ILIs) in acute myocardial infarction patients compared with patients hospitalised for acute non-vascular surgical conditions during the second wave of the 2009 influenza A H1N1 pandemic. DesignCase-control study. SettingCoronary care unit, acute cardiology and acute surgical admission wards in a major teaching hospital in London, UK. Participants134 participants (70 cases and 64 controls) aged [≥]40 years hospitalised for acute myocardial infarction and acute surgical conditions between 21 September 2009 and 28 February 2010, frequency-matched for gender, 5-year age-band and admission week. Primary exposureILI (defined as feeling feverish with either a cough or sore throat) within the last month. Secondary exposuresAcute respiratory illness within the last month not meeting ILI criteria; nasopharyngeal and throat swab positive for influenza virus. Results29 of 134 (21.6%) participants reported respiratory illness within the last month, of whom 13 (9.7%) had illnesses meeting ILI criteria. The most frequently reported category for timing of respiratory symptom onset was 8-14 days before admission (31% of illnesses). Cases were more likely than controls to report ILI--adjusted OR 3.17 (95% CI 0.61 to 16.47)--as well as other key respiratory symptoms, and were less likely to have received influenza vaccination--adjusted OR 0.46 (95% CI 0.19 to 1.12)--although the differences were not statistically significant. No swabs were positive for influenza virus. ConclusionsPoint estimates suggested that recent ILI was more common in patients hospitalised with acute myocardial infarction than with acute surgical conditions during the second wave of the influenza A H1N1 pandemic, and influenza vaccination was associated with cardioprotection, although the findings were not statistically significant. The study was underpowered, partly because the age groups typically affected by acute myocardial infarction had low rates of infection with the pandemic influenza strain compared with seasonal influenza.

The benefits of thermal clothing during winter in patients with heart failure: a pilot randomised controlled trial [RESEARCH]

Mon, 29 Apr 2013 00:00:00 +0000

ObjectivesTo examine whether providing thermal clothing to heart failure patients improves their health during winter. DesignA randomised controlled trial with an intervention group and a usual care group. SettingHeart failure clinic in a large tertiary referral hospital in Brisbane, Australia. ParticipantsEligible participants were those with known systolic heart failure who were over 50 years of age and lived in Southeast Queensland. Participants were excluded if they lived in a residential aged care facility, had incontinence or were unable to give informed consent. Fifty-five participants were randomised and 50 completed. InterventionsParticipants randomised to the intervention received two thermal hats and tops and a digital thermometer. Primary and secondary outcome measuresThe primary outcome was the mean number of days in hospital. Secondary outcomes were the number of general practitioner (GP) visits and self-rated health. ResultsThe mean number of days in hospital per 100 winter days was 2.5 in the intervention group and 1.8 in the usual care group, with a mean difference of 0.7 (95% CI -1.5 to 5.4). The intervention group had 0.2 fewer GP visits on average (95% CI -0.8 to 0.3), and a higher self-rated health, mean improvement -0.3 (95% CI -0.9 to 0.3). The thermal tops were generally well used, but even in cold temperatures the hats were only worn by 30% of the participants. ConclusionsThermal clothes are a cheap and simple intervention, but further work needs to be done on increasing compliance and confirming the health and economic benefits of providing thermals to at-risk groups. Trial registrationThe study was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12612000378820)

Obesity in young men, and individual and combined risks of type 2 diabetes, cardiovascular morbidity and death before 55 years of age: a Danish 33-year follow-up study [RESEARCH]

Mon, 29 Apr 2013 00:00:00 +0000

ObjectivesTo examine the association between body mass index (BMI) in young adulthood and cardiovascular risks, including venous thromboembolism, before 55 years of age. DesignCohort study using population-based medical databases. SettingOutcomes registered from all hospitals in Denmark from 1977 onwards. Participants6502 men born in 1955 and eligible for conscription in Northern Denmark. Main outcome measuresFollow-up began at participants' 22nd birthday and continued until death, emigration or 55 years of age, whichever came first. Using regression analyses, we calculated the risks and HRs, adjusting for cognitive test score and years of education. Results48% of all obese young men (BMI [≥]30 kg/m2) were either diagnosed with type 2 diabetes, hypertension, myocardial infarction, stroke or venous thromboembolism or died before reaching 55 years of age. Comparing obese men with normal weight men (BMI 18.5 to <25.0 kg/m2), the risk difference for any outcome was 28% (95% CI 19% to 38%) and the HR was 3.0 (95% CI 2.3 to 4.0). Compared with normal weight, obesity was associated with an event rate that was increased more than eightfold for type 2 diabetes, fourfold for venous thromboembolism and twofold for hypertension, myocardial infarction and death. ConclusionsIn this cohort of young men, obesity was strongly associated with adverse cardiometabolic events before 55 years of age, including venous thromboembolism. Compared with those of normal weight, young obese men had an absolute risk increase for type 2 diabetes, cardiovascular morbidity or premature death of almost 30%.

Coronary revascularisation in stable patients after an acute coronary syndrome: a propensity analysis of early invasive versus conservative management in a register-based cohort study [RESEARCH]

Wed, 24 Apr 2013 00:00:00 +0000

ObjectivesTo compare the effectiveness of in-hospital medical therapy versus coronary revascularisation added to medical therapy in patients who stabilised after an acute coronary syndrome (ACS). DesignPropensity score-matched cohort study from the database of the Tampere ACS registry. SettingA single academic hospital in Finland. Participants1149 patients with a recent ACS, but no serious coexisting conditions: recurrent ischaemic episodes despite adequate medical therapy, haemodynamic instability, overt congestive heart failure and serious ventricular arrhythmias. Primary and secondary outcome measuresThe composite endpoint of major acute cardiovascular events (MACEs): unstable angina requiring rehospitalisation, stroke, myocardial infarction and all-cause mortality, at 6-month follow-up. ResultsCompared with standard medical treatment, revascularisation was associated with a lower rate of MACEs at 6 months in patients of the first quintile (HR 0.81; 95% CI 0.66 to 0.99), but a higher rate of MACEs in the fifth quintile (HR 4.74, CI 1.36 to 16.49; p=0.014). There were no significant differences in the rates of MACEs in the remaining three quintiles. Patients of the first quintile were the oldest (79.7{+/-}8.3 years) and had a more significant (p<0.001) history of prior myocardial infarction (37%) and poor renal function (creatine, {micro}mol/l: 114.9{+/-}70.7). They also showed the highest C reactive protein (7.3{+/-}9.5 mg/l) levels. ConclusionsOur findings suggest that in-hospital coronary revascularisation did not lead to any advantage with signal of possible harm in the great majority of patients who stabilised after an ACS. An early invasive management strategy may be best reserved for elderly patients having high-risk clinical features and biochemical evidence of a strong inflammatory activity.

Aspirin treatment and risk of first incident cardiovascular diseases in patients with type 2 diabetes: an observational study from the Swedish National Diabetes Register [RESEARCH]

Sat, 20 Apr 2013 00:00:00 +0000

ObjectivesTo investigate the benefits and risks associated with aspirin treatment in patients with type 2 diabetes and no previous cardiovascular disease (CVD) in clinical practice. DesignPopulation-based cohort study between 2005 and 2009, mean follow-up 3.9 years. SettingHospital outpatient clinics and primary care in Sweden. ParticipantsMen and women with type 2 diabetes, free from CVD, including atrial fibrillation and congestive heart failure, at baseline, registered in the Swedish National Diabetes Register, with continuous low-dose aspirin treatment (n=4608) or no aspirin treatment (n=14 038). Main outcome measuresRisks of CVD, coronary heart disease (CHD), stroke, mortality and bleedings, associated with aspirin compared with no aspirin, were analysed in all patients and in subgroups by gender and estimated cardiovascular risk. Propensity scores were used to adjust for several baseline risk factors and characteristics at Cox regression, and the effect of unknown covariates was evaluated in a sensitivity analysis. ResultsThere was no association between aspirin use and beneficial effects on risks of CVD or death. Rather, there was an increased risk of non-fatal/fatal CHD associated with aspirin; HR 1.19 (95% CI 1.01 to 1.41), p=0.04. The increased risk of cardiovascular outcomes associated with aspirin was seen when analysing women separately; HR 1.41 (95% CI 1.07 to 1.87), p=0.02, and HR 1.28 (95% CI 1.01 to 1.61), p=0.04, for CHD and CVD, respectively, but not for men separately. There was a trend towards increased risk of a composite of bleedings associated with aspirin, n=157; HR 1.41 (95% CI 0.99 to 1.99). ConclusionsThe results support the trend towards more restrictive use of aspirin in patients with type 2 diabetes and no previous CVD. More research is needed to explore the differences in aspirin's effects in women and men.

Consumption of analgesics before a marathon and the incidence of cardiovascular, gastrointestinal and renal problems: a cohort study [RESEARCH]

Fri, 19 Apr 2013 00:00:00 +0000

ObjectivesTo prevent pain inhibiting their performance, many athletes ingest over-the-counter (OTC) analgesics before competing. We aimed at defining the use of analgesics and the relation between OTC analgesic use/dose and adverse events (AEs) during and after the race, a relation that has not been investigated to date. DesignProspective (non-interventional) cohort study, using an online questionnaire. SettingThe Bonn marathon 2010. Participants3913 of 7048 participants in the Bonn marathon 2010 returned their questionnaires. Primary and secondary outcomesIntensity of analgesic consumption before sports; incidence of AEs in the cohort of analgesic users as compared to non-users. ResultsThere was no significant difference between the premature race withdrawal rate in the analgesics cohort and the cohort who did not take analgesics ( controls'). However, race withdrawal because of gastrointestinal AEs was significantly more frequent in the analgesics cohort than in the control. Conversely, withdrawal because of muscle cramps was rare, but it was significantly more frequent in controls. The analgesics cohort had an almost 5 times higher incidence of AEs (overall risk difference of 13%). This incidence increased significantly with increasing analgesic dose. Nine respondents reported temporary hospital admittance: three for temporary kidney failure (post-ibuprofen ingestion), four with bleeds (post-aspirin ingestion) and two cardiac infarctions (post-aspirin ingestion). None of the control reported hospital admittance. ConclusionsThe use of analgesics before participating in endurance sports may cause many potentially serious, unwanted AEs that increase with increasing analgesic dose. Analgesic use before endurance sports appears to pose an unrecognised medical problem as yet. If verifiable in other endurance sports, it requires the attention of physicians and regulatory authorities.

Cardiovascular mortality in bipolar disorder: a population-based cohort study in Sweden [RESEARCH]

Thu, 18 Apr 2013 00:00:00 +0000

ObjectiveTo estimate the cardiovascular mortality among persons with bipolar disorder in Sweden compared to the general population. DesignPopulation register-based cohort study with a 20-year follow-up. SettingSweden. ParticipantsThe entire population of Sweden (n=10.6 million) of whom 17 101 persons were diagnosed with bipolar disorder between 1987 and 2006. Main outcome measuresMortality rate ratios (MRR), excess mortality (excess deaths), cardiovascular disorder (CVD) and specifically cerebrovascular disease, coronary heart disease, acute myocardial infarction, sudden cardiac deaths and hospital admission rate ratio (ARR). ResultsPersons with bipolar disorder died of CVD approximately 10 years earlier than the general population. One third (38%) of all deaths in persons with bipolar disorder were caused by CVD and almost half (44%) by other somatic diseases, whereas suicide and other external causes accounted for less than a fifth of all deaths (18%). Excess mortality of both CVD (n=824) and other somatic diseases (n=988) was higher than that of suicide and other external causes (n=675 deaths). MRRs for cerebrovascular disease, coronary heart disease and acute myocardial infarction were twice as high in persons with bipolar disorder compared to the general population. Despite the increased mortality of CVD, hospital admissions (ARR) for CVD treatment were only slightly increased in persons with bipolar disorder when compared to the general population. ConclusionsThe increased cardiovascular mortality in persons with bipolar disorder calls for renewed efforts to prevent and treat somatic diseases in this group. Specifically, our findings further imply that it would be critical to ensure that persons with bipolar disorder receive the same quality care for CVD as persons without bipolar disorder.

Risk assessment in hypertrophic cardiomyopathy: contemporary guidelines hampered by insufficient evidence

Mon, 15 Apr 2013 00:00:00 +0000

If it were not for the great variability among individuals, medicine might as well be a science and not an art. (Sir William Osler, 1892) The sudden unexpected death of an individual at any age has a profound effect on the family and the wider community and this is particularly significant when it affects a young person. Hypertrophic cardiomyopathy remains one of the common causes of sudden cardiac death (SCD) in young individuals.1 In a cohort of 744 patients with hypertrophic cardiomyopathy from the USA and Italy, where 86 (12%) died over an 8 (SD{+/-}7) year period of follow-up, three main modes of death were identified: sudden and unexpected (found mainly but not exclusively in adolescents and young adults); heart failure; and stroke, usually associated with the development of atrial fibrillation.2 The most common underlying pathophysiological mechanism leading to sudden death is the development of vent ...

Renal function estimations and dose recommendations for dabigatran, gabapentin and valaciclovir: a data simulation study focused on the elderly [RESEARCH]

Thu, 11 Apr 2013 00:00:00 +0000

ObjectivesThe thrombin inhibitor dabigatran is mainly excreted by the kidneys. We investigated whether the recommended method for estimation of renal function used in the clinical trials, the Cockcroft-Gault (CGold) equation and the estimated glomerular filtration rate (eGFR) modification of diet in renal disease equation 4 (MDRD4), differ in elderly participants, resulting in erroneously higher dose recommendations of dabigatran, which might explain the serious, even fatal, bleeding reported. The renally excreted drugs gabapentin and valaciclovir were also included for comparison. DesignA retrospective data simulation study. ParticipantsParticipants 65 years and older included in six different studies. Main outcome measureEstimated renal function by CG based on uncompensated ( old Jaffe' method) creatinine (CGold) or by MDRD4 based on standardised compensated P-creatinine traceable to isotope-dilution mass spectrometry, and the resulting doses. Results790 participants (432 females), mean age ({+/-}SD) 77.6{+/-}5.7 years. Mean estimated creatinine clearance (eCrCl) by the CGold equation was 44.2{+/-}14.8 ml/min, versus eGFR 59.6{+/-}20.7 ml/min/1.73 m2 with MDRD4 (p<0.001), absolute median difference 13.5, 95% CI 12.9 to 14.2. MDRD4 gave a significantly higher mean dose (valaciclovir +21%, dabigatran +25% and gabapentin +37%) of all drugs (p<0.001). With MDRD4 58% of the women would be recommended a full dose of dabigatran compared with 18% if CGold is used. ConclusionsMDRD4 would result in higher recommended doses of the three studied drugs to elderly participants compared with CG, particularly in women, and thus increased the risk of dose and concentration-dependent adverse reactions. It is important to know which method of estimation of renal function the Summary of Products Characteristics was based on, and use only that one when prescribing renally excreted drugs with narrow safety window. Doses based on recently developed methods for estimation of renal function may be associated with considerable risk of overtreatment in the elderly.

Assessment of statin-associated muscle toxicity in Japan: a cohort study conducted using claims database and laboratory information [RESEARCH]

Thu, 11 Apr 2013 00:00:00 +0000

ObjectiveTo estimate the incidence of muscle toxicity in patients receiving statin therapy by examining study populations, drug exposure status and outcome definitions. DesignA retrospective cohort study. Setting16 medical facilities in Japan providing information on laboratory tests performed in and claims received by their facilities between 1 April 2004 and 31 December 2010. ParticipantsA database representing a cohort of 35 903 adult statin (atorvastatin, fluvastatin, pitavastatin, pravastatin, rosuvastatin and simvastatin) users was studied. Use of interacting drugs (fibrates, triazoles, macrolides, amiodarone and ciclosporin) by these patients was determined. Main outcome measureStatin-associated muscle toxicity (the event') was identified based on a diagnosis of muscle-related disorders (myopathy or rhabdomyolysis) and/or abnormal elevation of creatine kinase (CK) concentrations. Events were excluded if the patients had CK elevation-related conditions other than muscle toxicity. Incidence rates for muscle toxicity were determined per 1000 person-years, with 95% CI determined by Poisson regression. ResultsA total of 18 036 patients accounted for 42 193 person-years of statin therapy, and 43 events were identified. The incidence of muscle toxicity in the patients treated with statins was 1.02 (95% CI 0.76 to 1.37)/1000 person-years. The estimates varied when outcome definitions were modified from 0.09/1000 person-years, which met both diagnosis and CK 10x greater than the upper limit of normal range (ULN) criteria, to 2.06/1000 person-years, which met diagnosis or CK 5x ULN criterion. The incidence of muscle toxicity was also influenced by the statin therapies selected, but no significant differences were observed. Among 2430 patients (13.5%) received interacting drugs with statins, only three muscle toxicity cases were observed (incidence: 1.69/1000 person-years). ConclusionsThis database study suggested that statin use is generally well tolerated and safe; however, the risk of muscle toxicity related to the use of interacting drugs requires further exploration.

Haemodynamic and structural correlates of the first and second heart sounds in pulmonary arterial hypertension: an acoustic cardiography cohort study [RESEARCH]

Mon, 8 Apr 2013 00:00:00 +0000

ObjectiveTo examine the relationship between acoustic characteristics of the first and second heart sounds (S1 and S2) and underlying cardiac structure and haemodynamics in patients with isolated pulmonary arterial hypertension (PAH) and controls. DesignProspective multicentre cohort study. SettingTertiary referral and community hospitals. ParticipantsWe prospectively evaluated 40 PAH patients undergoing right-heart catheterisation with contemporaneous digital acoustic cardiography (intensity and complexity) and two-dimensional transthoracic echocardiography. To normalise for differences in body habitus, acoustic variables were also expressed as a ratio (S2/S1). 130 participants (55 also had haemodynamic and/or echocardiographic assessment) without clinical or haemodynamic evidence of PAH or congestive heart failure acted as controls. ResultsPatients with PAH had higher mean pulmonary artery pressure (mPA; 40{+/-}13 vs 16{+/-}4 mm Hg, p<0.0001) and pulmonary vascular resistance (9{+/-}6 vs 1{+/-}1 Wood Units, p<0.0001) compared with controls, but cardiac index and mean pulmonary capillary wedge pressure were similar. More PAH patients had evidence of right ventricular (RV) dilation (50% vs 19%) and RV systolic dysfunction (41% vs 9%) in the moderate-severe range (all p<0.05). Compared with controls, the acoustic profiles of PAH patients were characterised by increased S2 complexity, S2/S1 complexity and S2/S1 intensity (all p<0.05). In the PAH cohort, S2 complexity was inversely related to S1 complexity. mPA was the only independent multivariate predictor of S2 complexity. The severity of RV enlargement and systolic impairment had reciprocal effects on the complexity of S2 (increased) and S1 (decreased). Decreased S1 complexity was also related to evidence of a small left ventricular cavity. ConclusionsAcoustic characteristics of both S1 and S2 are related to the severity of PAH and are associated with RV enlargement and systolic dysfunction. The reciprocal relationship between S2 and S1 complexity may also reflect the underlying ventricular interaction associated with PAH.

Right ventricular ejection fraction during exercise as a predictor of mortality in patients awaiting lung transplantation: a cohort study [RESEARCH]

Mon, 8 Apr 2013 00:00:00 +0000

ObjectiveThe occurrence of right ventricular dysfunction is a well-known indicator of poor prognosis in patients with chronic cardiopulmonary disease. The role of right ventricular ejection fraction (RVEF) at rest and during exercise as predictors of outcome in patients awaiting lung transplantation (LTx) is unclear. DesignWe performed a retrospective analysis of lung transplant candidates who had undergone equilibrium radionuclide angiography (ERNA), to determine baseline and exercise RVEF. Lung function, gas exchange and pulmonary haemodynamics were also assessed. Patients and main outcome measures152 patients (mean age 47{+/-}11 years; 59% women) were included in the study. Primary endpoint was death on the waiting list for LTx. Main diagnoses were -1 antitrypsin deficiency (n=35), chronic obstructive pulmonary disease (n=41), cystic fibrosis (n=10), interstitial lung disease (n=34) and pulmonary arterial hypertension (n=32). Twenty-five patients died (16, 4%). LTx was performed in 121 patients. The mean RVEF at rest was equal to mean RVEF during exercise (38{+/-}12%). In univariate analysis RVEF at rest, RVEF during exercise, heart rate and forced volume capacity (FVC) % of predicted were factors significantly associated with risk of death. In multivariate analysis RVEF during exercise and FVC% of predicted were independent predictors of death. ConclusionsIn lung transplant candidates, right ventricular function during exercise is a stronger predictor of outcome than right ventricular function at rest. RVEF during exercise assessed by ERNA could be incorporated into priority-based allocation algorithms for LTx.

Acute electrocardiographic changes during smoking: an observational study [RESEARCH]

Fri, 5 Apr 2013 00:00:00 +0000

ObjectiveTo study the temporal relationship of smoking with electrophysiological changes. DesignProspective observational study. SettingTertiary cardiac center. ParticipantsMale smokers with atypical chest pain were screened with a treadmill exercise test (TMT). A total of 31 such patients aged 49.8{+/-}10.5 years, in whom TMT was either negative or mildly positive were included. Heart rate variability (HRV) parameters of smokers were compared to those of 15 healthy non-smoking participants. InterventionsAll patients underwent a 24 h Holter monitoring to assess ECG changes during smoking periods. ResultsHeart rate increased acutely during smoking. Mean heart rate increased from 83.8{+/-}13.7 bpm 10 min before smoking, to 90.5{+/-}16.4 bpm during smoking, (p<0.0001) and returned to baseline after 30 min. Smoking was also associated with increased ectopic beats (mean of 5.3/h prior to smoking to 9.8/h during smoking to 11.3/h during the hour after smoking; p<0.001). Three patients (9.7%) had significant ST-T changes after smoking. HRV index significantly decreased in smokers (15.2{+/-}5.3) as compared to non-smoking controls participants (19.4{+/-}3.6; p=0.02), but the other spectral HRV parameters were comparable. ConclusionsHeart rate and ectopic beats increase acutely following smoking. Ischaemic ST-T changes were also detected during smoking. Spectral parameters of HRV analysis of smokers remained in normal limits, but more importantly geometrical parameter--HRV index--showed significant abnormality.

Real time monitoring of risk-adjusted paediatric cardiac surgery outcomes using variable life-adjusted display: implementation in three UK centres

Fri, 5 Apr 2013 00:00:00 +0000

ObjectiveTo implement routine in-house monitoring of risk-adjusted 30-day mortality following paediatric cardiac surgery. DesignCollaborative monitoring software development and implementation in three specialist centres. Patients and methodsAnalyses incorporated 2 years of data routinely audited by the National Institute of Cardiac Outcomes Research (NICOR). Exclusion criteria were patients over 16 or undergoing non-cardiac or only catheter procedures. We applied the partial risk adjustment in surgery (PRAiS) risk model for death within 30 days following surgery and generated variable life-adjusted display (VLAD) charts for each centre. These were shared with each clinical team and feedback was sought. ResultsParticipating centres were Great Ormond Street Hospital, Evelina Children's Hospital and The Royal Hospital for Sick Children in Glasgow. Data captured all procedures performed between 1 January 2010 and 31 December 2011. This incorporated 2490 30-day episodes of care, 66 of which were associated with a death within 30 days.The VLAD charts generated for each centre displayed trends in outcomes benchmarked to recent national outcomes. All centres ended the 2-year period within four deaths from what would be expected. The VLAD charts were shared in multidisciplinary meetings and clinical teams reported that they were a useful addition to existing quality assurance initiatives. Each centre is continuing to use the prototype software to monitor their in-house surgical outcomes. ConclusionsTimely and routine monitoring of risk-adjusted mortality following paediatric cardiac surgery is feasible. Close liaison with hospital data managers as well as clinicians was crucial to the success of the project.

Male pattern baldness and its association with coronary heart disease: a meta-analysis [RESEARCH]

Wed, 3 Apr 2013 00:00:00 +0000

ObjectiveTo confirm the association between male pattern baldness and coronary heart disease (CHD). DesignMeta-analysis of observational studies. Data sourcesMedline and the Cochrane Library were searched for articles published up to November 2012 using keywords that included both baldness' and coronary heart disease' and the reference lists of those studies identified were also searched. Study selectionObservational studies were identified that reported risk estimates for CHD related to baldness. Two observers independently assessed eligibility, extracted data and assessed the possibility of bias. Data synthesisThe adjusted relative risk (RR) and 95% CI were estimated using the DerSimonian-Laird random-effect model. Results850 possible studies, 3 cohort studies and 3 case-control studies were selected (36 990 participants). In the cohort studies, the adjusted RR of men with severe baldness for CHD was 1.32 (95% CI 1.08 to 1.63, p=0.008, I2=25%) compared to those without baldness. Analysis of younger men (<55 or [≤]60 years) showed a similar association of CHD with severe baldness (RR 1.44, 95% CI 1.11 to 1.86, p=0.006, I2=0%). In three studies employing the modified Hamilton scale, vertex baldness was associated with CHD and the relation depended on the severity of baldness (severe vertex: RR 1.48 (1.04 to 2.11, p=0.03); moderate vertex: RR 1.36 (1.16 to 1.58, p<0.001); mild vertex: RR 1.18 (1.04 to 1.35, p<0.001)). However, frontal baldness was not associated with CHD (RR 1.11 (0.92 to 1.32, p=0.28)). ConclusionsVertex baldness, but not frontal baldness, is associated with an increased risk of CHD. The association with CHD depends on the severity of vertex baldness and also exists among younger men. Thus, vertex baldness might be more closely related to atherosclerosis than frontal baldness, but the association between male pattern baldness and CHD deserves further investigation.

The safety and efficacy of intracoronary nitrite infusion during acute myocardial infarction (NITRITE-AMI): study protocol of a randomised controlled trial [PROTOCOL]

Tue, 2 Apr 2013 00:00:00 +0000

IntroductionAcute myocardial infarction (AMI) is a major cause of death and disability in the UK and worldwide. Presently, timely and effective reperfusion with primary percutaneous coronary intervention (PPCI) remains the most effective treatment strategy for limiting infarct size, preserving left ventricular ejection fraction (LVEF) and improving clinical outcomes. However, the process of reperfusion can itself induce cardiomyocyte death, known as myocardial reperfusion injury, for which there is currently no effective therapy. Extensive preclinical evidence exists to suggest that sodium nitrite (as a source of endogenous nitric oxide) is an effective therapeutic strategy for preventing myocardial reperfusion injury. The purpose of NITRITE-AMI is to test whether sodium nitrite reduces reperfusion injury and subsequent infarct size in patients undergoing PPCI for MI. Methods and designNITRITE-AMI is a double-blind, randomised, single-centre, placebo-controlled trial to determine whether intracoronary nitrite injection reduces infarct size in patients with myocardial infarction undergoing primary angioplasty. The study will enrol 80 patients presenting with ST-elevation myocardial infarction. Patients will be randomised to receive either a bolus of intracoronary sodium nitrite or placebo (sodium chloride) at the time of PPCI. The primary outcome is infarct size assessed by creatine kinase area under the curve (AUC) over 48 h. Secondary endpoints include troponin T AUC and infarct size, LV dimensions and myocardial salvage index assessed by cardiac MR (CMR), markers of platelet reactivity and inflammation, the safety and tolerability of intracoronary nitrite, and 1 year major adverse cardiac events. Ethics and disseminationThe study is approved by the local ethics committee (NRES Committee London West London: 11/LO/1500) and by the Medicines and Healthcare Products Regulatory Agency (MHRA) (EudraCT nr. 2010-022460-12). The results of the trial will be published according to the CONSORT statement and will be presented at conferences and reported in peer-reviewed journals. Trial registrationUnited Kingdom Clinical Research Network (Study ID 12117), http://clinicaltrials.gov (NCT01584453) and Current Controlled Trials (ISRCTN:38736987).

ExPeKT--Exploring prevention and knowledge of venous thromboembolism: a two-stage, mixed-method study protocol [PROTOCOL]

Tue, 2 Apr 2013 00:00:00 +0000

IntroductionThere is little awareness of venous thromboembolism (VTE) in the public arena. Most commonly known causes are--travellers' thrombosis and thrombosis associated with oral contraception, both frequently referred to in the media. However, VTE is a substantial healthcare problem, resulting in mortality, morbidity and economic cost. Most hospitalised patients have one or more risk factors for VTE. Around 60% of people undergoing hip or knee replacement will suffer a deep vein thrombosis without preventative intervention. Studies demonstrate a risk reduction for VTE of up to 70% with preventative medicine for medical and surgical conditions: cancer, orthopaedic surgery, general surgery and acutely ill medical admissions. Results will be used to identify methods of increasing knowledge of VTE prevention and for the development of educational and patient information materials. Methods and analysisA two-stage, mixed-method study using surveys with primary healthcare professionals and patients followed by interviews with primary healthcare professionals, patients, acute trusts and other relevant organisations. Survey and qualitative interview data will examine the current practice of thromboprophylaxis, and the knowledge and experience of VTE prevention for the development of education initiatives for primary healthcare professionals and patients to adopt thromboprophylaxis outside the hospital setting. As this is a scientific exploratory study for the generation, rather than testing, of new hypotheses a sample-size analysis is not called for. Survey data will be analysed using SPSS version 20. Open-ended responses will be analysed using qualitative thematic methods. The recorded and transcribed semistructured interview data will be analysed using constant comparative methods. Ethics and disseminationEthics approval has been provided by the National Research Ethics Committee (reference: 11/H0605/5) and site-specific R&D approval granted by the relevant R&D National Health Service trusts. Findings will be disseminated at healthcare and academic conferences and written for peer-reviewed publication. Trial grant numberNIHR RP-PG-0608-10073

Loss to specialist follow-up in congenital heart disease; out of sight, out of mind

Mon, 1 Apr 2013 00:00:00 +0000

ObjectiveTo evaluate the scale and clinical importance of loss to follow-up of past patients with serious congenital heart disease, using a common malformation as an example. To better understand the antecedents of loss to specialist follow-up and patients' attitudes to returning. DesignCohort study using NHS number functionality. Content and thematic analysis of telephone interviews of subset contacted after loss to follow-up. Patients, intervention and settingLongitudinal follow-up of complete consecutive list of all 1085 UK patients with repair of tetralogy of Fallot from single institution 1964-2009. Main outcome measuresSurvival, freedom from late pulmonary valve replacement, loss to specialist follow-up, shortfall in late surgical revisions related to loss to follow-up. Patients' narrative about loss to follow-up. Results216 (24%) of patients known to be currently alive appear not to be registered with specialist clinics; some are seen in general cardiology clinics. Their median age is 32 years and median duration of loss to follow-up is 22 years; most had been lost before Adult Congenital services had been consolidated in their present form. 48% of the late deaths to date have occurred in patients not under specialist follow-up. None of those lost to specialist follow-up has had secondary pulmonary valve replacement while 188 patients under specialist care have. Patients lost to specialist follow-up who were contacted by telephone had no knowledge of its availability. ConclusionsLoss to specialist follow-up, typically originating many years ago, impacts patient management.

Miscarriage and future maternal cardiovascular disease: a systematic review and meta-analysis

Thu, 28 Mar 2013 00:00:00 +0000

ContextThe 2011 American Heart Association guidelines identified pregnancy complications as a risk factor for cardiovascular disease in women. However, miscarriage was not mentioned within the guidelines, and there is no consensus on the association between miscarriage and future risk of cardiovascular disease. ObjectiveTo confirm or refute the association, a meta-analysis of published papers was conducted. Data sourcesPubMed, Web of Knowledge and Scopus were systematically searched to identify appropriate articles. Reference lists were then hand searched for additional relevant titles. Study SelectionTo be included, articles had to assess the association between miscarriage and subsequent cardiovascular disease in otherwise healthy women. Only women who had miscarriages were considered exposed. Pooled association measures, using random effects meta-analysis, were calculated for coronary heart disease and cerebrovascular disease. Publication bias and between-study heterogeneity were evaluated. Data ExtractionTwo authors individually reviewed all studies and extracted data on patient and study characteristics along with cardiovascular outcomes. Results10 studies were identified, with 517 504 individuals included in the coronary heart disease meta-analysis and 134 461 individuals in the cerebrovascular disease analysis. A history of miscarriage was associated with a greater odds of developing coronary heart disease, OR (95% CI) =1.45 (1.18 to 1.78), but not with cerebrovascular disease, OR=1.11 (0.72 to 1.69). There was a strong association between recurrent miscarriage and coronary heart disease OR=1.99 (1.13 to 3.50). Evidence was found for moderate between-study heterogeneity and publication bias in the coronary heart disease analysis. ConclusionsThe meta-analysis indicates that a history of miscarriage or recurrent miscarriage is associated with a greater risk of subsequent coronary heart disease.

CHADS2 and CHA2DS2-VASc score to assess risk of stroke and death in patients paced for sick sinus syndrome

Thu, 28 Mar 2013 00:00:00 +0000

Intravenous nicardipine and labetalol use in hypertensive patients with signs or symptoms suggestive of end-organ damage in the emergency department: a subgroup analysis of the CLUE trial [RESEARCH]

Tue, 26 Mar 2013 00:00:00 +0000

ObjectiveTo compare the efficacy of Food and Drug Administration recommended dosing of nicardipine versus labetalol for the management of hypertensive patients with signs and/or symptoms (S/S) suggestive of end-organ damage (EOD). DesignSecondary analysis of the multicentre prospective, randomised CLUE trial. Setting13 academic emergency departments in the USA. ParticipantsEligible patients had two systolic blood pressure (SBP) measures [≥]180 mm Hg at least 10 min apart, no contraindications to nicardipine or labetalol and predefined S/S suggestive of EOD on arrival. InterventionsMedications were administered by continuous infusion (nicardipine) or repeat intravenous bolus (labetalol) for a study period of 30 min or until a specified target SBP {+/-}20 mm Hg was achieved. Primary outcome measurePercentage of participants achieving a predefined target SBP range (TR) defined as an SBP within {+/-}20 mm Hg as established by the treating physician. ResultsOf the 141 eligible patients, 49.6% received nicardipine, 51.7% were women and 81.6% were black. Mean age was 52.2{+/-}13.9 years. Median initial SBP did not differ in the nicardipine (210.5 (IQR 197-226) mm Hg) and labetalol (210 (200-226) mm Hg) groups (p=0.862). Nicardipine patients were more likely to have a history of diabetes (41.4% vs 25.7%, p=0.05) but there were no other historical, demographic or laboratory differences between groups. Within 30 min, nicardipine patients more often reached the target SBP range than those receiving labetalol (91.4% vs 76.1%, difference=15.3% (95% CI 3.5% to 27.3%); p=0.01). On multivariable modelling with adjustment for gender and clinical site, nicardipine patients were more likely to be in TR by 30 min than patients receiving labetalol (OR 3.65, 95% CI 1.31 to 10.18, C statistic=0.72). ConclusionsIn the setting of hypertension with suspected EOD, patients treated with nicardipine are more likely to reach prespecified SBP targets within 30 min than patients receiving labetalol. Clinical Trial RegistrationNCT00765648, clinicaltrials.gov

Descriptive study of possible link between cardioankle vascular index and homocysteine in vascular-related diseases [RESEARCH]

Mon, 25 Mar 2013 00:00:00 +0000

ObjectivesCardioankle vascular index (CAVI) is a new index of arterial stiffness independent of immediate blood pressure. Homocysteine (Hcy) is an independent risk factor for vascular diseases. The aim of this study was to investigate the relationship between Hcy and CAVI in the vascular-related diseases. DesignDescriptive research. Participants88 patients (M/F 46/42) with or without hypertension, coronary artery disease or arteriosclerosis obliterans were enrolled to our study. They were divided into two groups according to the level of Hcy. MethodsCAVI, carotid-femoral pulse wave velocity (CF-PWV) and carotid-radial pulse wave velocity (CR-PWV) were measured by VS-1000 and Complior apparatus. ResultsThere was significant correlation between Hcy and CF-PWV, CR-PWV, CAVI in the entire group (r=0.33, p=0.002; r=0.51, p<0.001; r=0.42, p<0.001, respectively). And there was significant correlation between Hcy and CF-PWV, CR-PWV, CAVI in the vascular-related disease group (r=0.23, p=0.048; r=0.51, p<0.001; r=0.392, p=0.001, respectively). The level of Hcy was significantly higher in patients with one or more vascular diseases than in patients without vascular diseases. The levels of CF-PWV, CR-PWV and CAVI were significantly higher in Hcy [≥]15 mol/l group than in Hcy <5 mol/l group (13.7{+/-}3.0 vs 10.8{+/-}2.5, p < 0.001; 10.6{+/-}2.1 vs 9.2{+/-}1.6, p=0.001; 9.30{+/-}2.1 vs 7.79{+/-}2.1, p=0.001, respectively). Multiple linear regression showed that Hcy, body mass index (BMI) and age were independent associating factors of CAVI in the entire study group ({beta}=0.421, p=0.001; {beta}=-0.309, p=0.006; {beta}=0.297, p=0.012, respectively). And Hcy, BMI and age were independent influencing factors of CAVI in the vascular-related disease group ({beta}=0.434, p=0.001; {beta}=-0.331, p=0.009; {beta}=0.288, p=0.022, respectively). ConclusionsCAVI was positively correlated with Hcy in the vascular-related diseases.

Would primary healthcare professionals prescribe a polypill to manage cardiovascular risk? A qualitative interview study [RESEARCH]

Mon, 25 Mar 2013 00:00:00 +0000

ObjectivesA polypill' containing both blood pressure-lowering and cholesterol-lowering drugs could prevent up to 80% of cardiovascular disease events. Since little is known about the attitudes of primary healthcare professionals to use of such a pill for cardiovascular disease prevention, this study aimed to investigate opinions. DesignSemistructured interviews were conducted with participants. A qualitative description approach was used to analyse and report the results. SettingParticipants were recruited from nine primary care practices in Birmingham. ParticipantsSixteen healthcare professionals (11 primary care physicians and 5 practice nurses) were selected through purposive sampling to maximise variation of characteristics. Outcome measuresOutcome measures for this study were: the attitude of healthcare professionals towards the use of a polypill for primary and secondary cardiovascular disease prevention; their views on monitoring the drug; and the factors influencing their willingness to prescribe the medication. ResultsHealthcare professionals expressed considerable concern over using a polypill for primary prevention for all people over a specific age, although there was greater acceptance of its use for secondary prevention. Regularly monitoring patients taking the polypill was deemed essential. Evidence of effectiveness, patient risk level and potential medicalisation were key determinants in willingness to prescribe such a pill. ConclusionsPrimary healthcare professionals have significant concerns about the use of a polypill, particularly in the prevention of cardiovascular disease in people who are not regarded as being at high risk'. If a population-based polypill strategy is to be successfully implemented, healthcare professionals will need to be convinced of the potential benefits of a drug-based population approach to prevention.

Myocardial function in premature infants: a longitudinal observational study [RESEARCH]

Mon, 25 Mar 2013 00:00:00 +0000

ObjectivesGestational and chronological age may have an impact on myocardial function. We studied the longitudinal changes of the atrioventricular tissue Doppler velocities in premature infants through the neonatal transitional period and at expected term and explored the reproducibility of the measurements. DesignProspective, observational and longitudinal cohort study. SettingTwo-centre study, from a secondary and a tertiary neonatal intensive care unit. Participants55 infants (29 males) with gestational age 31-35 weeks and birth weight 1127-2836 grams. Primary and secondary outcome measuresPulsed-wave atrioventricular left, septum and right ventricular annulus tissue Doppler systolic (S'), early diastolic (E') and late diastolic (A') velocities measured by repeated echocardiographic examinations days 1, 2 and 3 and at expected term. ResultsAll velocities increased significantly from the neonatal period to expected term (p<0.001). We found a significant correlation between gestational age and right-sided S', E' and A' on day 1 (Pearson correlation 0.32-0.46, p<0.05), for S' in all three walls and septal E' and A' on day 2 (Pearson correlation 0.27-0.49, p<0.05). There was a moderate linear correlation between left ventricle end-diastolic length and septal and right S' at term and for septal E' and A' at day 1 (Pearson correlation 0.30-0.56, p<0.05). We found no correlation between heart rate and tissue Doppler velocities when controlling for the effect of fusion. Continuous positive airway pressure showed moderate effect where as persistence of the ductus arteriosus showed no effect on the tissue Doppler velocities. The E'/A' relationship was consistently reversed throughout the study with frequently fused diastolic tissue velocity signals. ConclusionsPulsed-wave atrioventricular annulus tissue Doppler velocities were related to gestational age, postnatal age and ventricular size. Right ventricle velocities showed more pronounced increase with postnatal maturation than left ventricle velocities. The degree of E'/A' fusion influenced the diastolic tissue Doppler velocities and should be reported if present.

Reduction in arterial stiffness and vascular age by naltrexone-induced interruption of opiate agonism: a cohort study [RESEARCH]

Thu, 21 Mar 2013 00:00:00 +0000

ObjectiveTo prospectively assess if opiate antagonist treatment or the opiate-free status could reverse opiate-related vasculopathy. DesignLongitudinal Open Observational, Serial N of One', over 6.5 years under various treatment conditions: opiate dependence, naltrexone and opiate-free. SettingPrimary care, Australia. Participants20 opiate-dependent patients (16 males: 16 cases of buprenorphine 4.11{+/-}1.17 mg, two of methadone 57.5{+/-}12.5 mg and two of heroin 0.75{+/-}0.25 g). InterventionStudies of central arterial stiffness and vascular reference age (RA) were performed longitudinally by SphygmoCor Pulse Wave Analysis (AtCor, Sydney). Primary outcomesPrimary outcome was vascular age and arterial stiffness accrual under different treatment conditions. ResultsThe mean chronological age (CA) was 33.62{+/-}2.03 years. The opiate-free condition was associated with a lower apparent vascular age both in itself (males: p=0.0402 and females: p=0.0360) and in interaction with time (males: p=0.0001 and females: p=0.0004), and confirmed with other measures of arterial stiffness. The mean modelled RA was 38.82, 37.73 and 35.05 years in the opiate, naltrexone and opiate-free conditions, respectively. The opiate-free condition was superior to opiate agonism after full multivariate adjustment (p=0.0131), with modelled RA/CA of 1.0173, 0.9563 and 0.8985 (reductions of 6.1% and 11.9%, respectively). ConclusionsData demonstrate that opiate-free status improves vascular age and arterial stiffness in previous chronic opiate users. The role of opiate antagonist treatment in achieving these outcomes requires future clarification and offers hope of novel therapeutic remediation.

Differences between self-reported and verified adverse cardiovascular events in a randomised clinical trial [RESEARCH]

Mon, 18 Mar 2013 00:00:00 +0000

ObjectivesIn clinical trials, adverse events are usually self-reported but may be adjudicated if serious or of particular interest. After adjudicating cardiovascular events for a 5-year calcium supplement trial, we observed discrepancies between self-reported and verified events. We systematically analysed those differences to assess their importance. DesignSecondary analysis of adverse cardiovascular events in a 5-year, randomised, placebo-controlled trial of calcium supplementation (1 g calcium daily) in 1471 postmenopausal women (mean age 74 years). SettingClinical research centre. MethodsThe participant's medical records were reviewed for all self-reported myocardial infarctions (MIs) or strokes, and the event independently adjudicated. Cause of death was obtained from hospital records or death certificates. To identify unreported events, the national hospital discharge database was searched and related hospital records were reviewed. Results45 women reported 64 MIs, of which 33 (52%) were verified after adjudication. An additional 25 MIs were identified: 1 during adjudication of other events, 21 from the hospital discharge database, 3 from death certificates. 68 women reported 86 strokes of which 50 (58%) were verified. An additional 13 strokes were identified: 7 during adjudication of reported transient ischaemic attacks, 5 from the hospital discharge database, 1 from death certificates. Therefore, 43% of verified MIs and 21% of verified strokes were not reported to investigators. For non-adjudicated discharge codes, 10% of MIs and 22% of strokes were not verified after adjudication. Nineteen per cent of verified MIs and 27% of verified strokes were not identified in discharge coding or death certificates. Neither the event source nor the level of adjudication altered the relationship between treatment allocation and cardiovascular events. ConclusionsWhen adverse event accuracy is critical, researchers should consider adjudicating self-reported events and hospital discharge codes, and attempt to identify unreported events. Trial registrationAustralia New Zealand Clinical Trials registry: ACTRN 012605000242628.

Cardiovascular disease risk scores in identifying future frailty: the Whitehall II prospective cohort study

Sat, 16 Mar 2013 00:00:00 +0000

The clustering of cardiovascular disease risk factors and their impacts on annual medical expenditure in Japan: community-based cost analysis using Gamma regression models [RESEARCH]

Fri, 15 Mar 2013 00:00:00 +0000

ObjectiveThe clustering of cardiovascular disease (CVD) risk factors is a serious threat for increasing medical expenses. The age-specific proportion and distribution of medical expenditure attributable to CVD risk factors, especially focused on the elderly, is thus indispensable for formulating public health policy given the extent of the ageing population in developed countries. DesignCost analysis using individuals' medical expenses and their corresponding health examination measures. SettingShiga prefecture, Japan, from April 2000 to March 2006. Participants33 213 participants aged 40 years and over. Main outcome measuresMean medical expenditure per year. MethodsGamma regression models were applied to examine how the number of CVD risk factors affects mean medical expenditure. The four CVD risk factors analysed in this study were defined as follows: hypertension (systolic blood pressure [≥]140 mm Hg or diastolic blood pressure [≥]90 mm Hg), hypercholesterolaemia (serum total cholesterol [≥]240 mg/dl), high blood glucose (casual blood glucose [≥]200 mg/dl) and smoking (current smoker). Sex-specific and age-specific investigations were carried out on the elderly (aged 65 and over) and non-elderly (aged 40-64) populations. ResultsThe mean medical expenditure (per year) for the no CVD risk-factor group was only 110 000 yen at age 50 (men, 110 708 yen; women, 107 109 yen), but this expenditure was 6-7 times higher for 80-year-olds who have three or four CVD risk factors (men, 603 351 yen; women, 765 673 yen). The total overspend (excess fraction) was larger for the non-elderly (men, 15.4%; women, 11.1%) than that for the elderly (men, 0.1%; women, 5.2%) and largely driven by people with one or two CVD risk factors, except for elderly men. ConclusionsThe age-specific proportion and distribution of medical expenditure attributable to CVD risk factors showed that a high-risk approach for the elderly and a population approach for the majority are both necessary to reduce total medical expenditure in Japan.

Nocturnal hypoxaemia in patients with Eisenmenger syndrome: a cohort study [RESEARCH]

Mon, 11 Mar 2013 00:00:00 +0000

ObjectivesThe objective of the study was to find the prevalence of sleep-related disturbances in patients of Eisenmenger syndrome. DesignProspective observational study. SettingTertiary care referral centre in North India. ParticipantsThe study included 25 patients with Eisenmenger syndrome (mean age 25.2{+/-}9.6 years, 18 men) and 12 patients with cyanotic congenital heart disease with pulmonary stenosis physiology (mean age 20.5{+/-}8.5 years, 8 men) as controls. InterventionsAll the patients underwent an overnight comprehensive polysomnogram study and pulmonary function testing. Main outcome measureOxygen desaturation index, which is the number of oxygen drops per hour. ResultsThe patients and controls had significant nocturnal hypoxaemia in the absence of apnoea and hypopnoea. The mean oxygen drop index in Eisenmenger syndrome group was 9.0{+/-}6.2 and in the control group was 8.0{+/-}5.9 (p=0.63). The apnoea-hypopnoea index was 3.37{+/-}5.0 in the Eisenmenger syndrome group and was 2.1{+/-}3.6 in the control group. Patients with >10 oxygen drops per hour had significantly higher haemoglobin (17.2{+/-}1.3% vs 14.4{+/-}1.5%, p<0.001) than those with oxygen drops less than 10. ConclusionsEisenmenger syndrome patients have significant nocturnal hypoxaemia unrelated to hypopnoea and apnoea. Nocturnal desaturation occurred more frequently in patients with greater haemoglobin values.

Statin use and clinical outcomes in older men: a prospective population-based study [RESEARCH]

Sat, 9 Mar 2013 00:00:00 +0000

ObjectiveThe aim of this analysis was to investigate the relationship of statins with institutionalisation and death in older men living in the community, accounting for frailty. DesignProspective cohort study. SettingCommunity-dwelling men participating in the Concord Health and Ageing in Men Project, Sydney, Australia. ParticipantsMen aged [≥]70 years (n=1665). MeasurementsData collected during baseline assessments and follow-up (maximum of 6.79 years) were obtained. Information regarding statin use was captured at baseline, between 2005 and 2007. Proportional hazards regression analysis was conducted to estimate the risk of institutionalisation and death according to statin use (exposure, duration and dose) and frailty status, with adjustment for sociodemographics, medical diagnosis and other clinically relevant factors. A secondary analysis used propensity score matching to replicate covariate adjustment in regression models. ResultsAt baseline, 43% of participants reported taking statins. Over 6.79 years of follow-up, 132 (7.9%) participants were institutionalised and 358 (21.5%) participants had died. In the adjusted models, baseline statin use was not statistically associated with increased risk of institutionalisation (HR=1.60; 95% CI 0.98 to 2.63) or death (HR=0.88; 95% CI 0.66 to 1.18). There was no significant association between duration and dose of statins used with either outcome. Propensity scoring yielded similar findings. Compared with non-frail participants not prescribed statins, the adjusted HR for institutionalisation for non-frail participants prescribed statins was 1.43 (95% CI 0.81 to 2.51); for frail participants not prescribed statins, it was 2.07 (95% CI 1.11 to 3.86) and for frail participants prescribed statins, it was 4.34 (95% CI 2.02 to 9.33). ConclusionsThese data suggest a lack of significant association between statin use and institutionalisation or death in older men. These findings call for real-world trials specifically designed for frail older people to examine the impact of statins on clinical outcomes.

Assessment of a multimarker strategy for prediction of mortality in older heart failure patients: a cohort study [RESEARCH]

Sat, 9 Mar 2013 00:00:00 +0000

ObjectivePrimarily to develop a multimarker score for prediction of 3-year mortality in older patients with decompensated heart failure (HF). DesignProspective cohort study. SettingSecondary care. Single centre. Patients and biomarkers131 patients, aged [≥]65 years, with decompensated HF were included. Assessment of biomarkers was performed at discharge. Primary outcome measure3-year mortality. ResultsMean age was 73{+/-}11 years; mean left ventricular ejection fraction , 43{+/-}14%; 53% were male. The 3-year mortality was 53.4%. The following N-terminal brain natriuretic peptide (NTproBNP) levels could optimally stratify mortality: <2000 ng/l (n=39), 30.8% mortality; 2000-8000 ng/l (n=58), 51.7% mortality; and >8000 ng/l (n=34), 82.4% mortality. However, in the 2000-8000 ng/l range, NTproBNP levels had low-prognostic capacity, based on the area under the receiver operating characteristic curve (AUC=0.53; 95% CI 0.40 to 0.67). In this group, multivariate analysis identified age, cystatin C (CysC), and troponin T (TnT) levels as independent risk factors. A risk score based on these three risk factors separated a high-risk and low-risk groups within the NTproBNP range of 2000-8000 ng/l. The score exhibited a significantly higher AUC (0.75; 95% CI 0.62 to 0.86) than NTproBNP alone (p=0.03) in this NTproBNP group and had similar prognostic capacity as NTproBNP in patients below or above this NTproBNP range (p=0.57). Net reclassification improvement and integrated discriminatory improvement in the group with NTproBNP levels between 2000 and 8000 ng/l was 54% and 23%, respectively, and in the whole cohort 22% and 11%, respectively. ConclusionsOur results suggested that, to assess risk in HF, older patients required significantly higher levels of NTproBNP than younger patients. Furthermore, a risk score that included TnT and CysC at discharge, and age could improve risk stratification for mortality in older patients with HF in particular when NTproBNP was moderately elevated.

Cadmium exposure, intercellular adhesion molecule-1 and peripheral artery disease: a cohort and an experimental study [RESEARCH]

Wed, 6 Mar 2013 00:00:00 +0000

ObjectivesCadmium exposure has been found to be associated with atherosclerotic plaques in the carotid arteries and with circulating levels of the proatherogenic intercellular adhesion molecule-1 (ICAM-1). The research questions were (1) if blood and urinary cadmium levels are associated with low ankle-brachial index (ABI) as a measure of peripheral artery disease in a longitudinal study and (2) if ICAM-1 mediates proatherogenic effects of cadmium exposure. DesignA prospective, observational cohort study with a 5-year follow-up and an experimental study of cultured human aortic endothelial cells exposed to cadmium. SettingResearch unit at a university hospital. ParticipantsA cohort of 64-year-old women (n=489) recruited by stratified sampling of similarly sized groups with normal, impaired and diabetic glucose tolerance as assessed in a population-based screening examination. Primary and secondary outcome measuresABI (ratio of the systolic blood pressures in the tibial and brachial arteries [≤]0.9 in any artery) in relation to cadmium exposure; ICAM-1 concentrations in the cell culture medium after cadmium incubation. ResultsHigh (tertile 3 vs 1) concentrations of blood (B-Cd) or creatine-adjusted urinary cadmium (U-Cd) at baseline were found to predict low ABI after adjustment for smoking and other cardiovascular risk factors at baseline. For U-Cd the OR was 2.5 (95% CI 1.1 to 5.8). After exclusion of participants with ultrasound-assessed femoral atherosclerosis at baseline the OR for U-Cd was unchanged, and for B-Cd it was 3.7 (95% CI 1.05 to 13.3). Inclusion of serum ICAM-1 levels did not affect the cadmium-related ORs in multivariate analyses. The experimental study did not show any cadmium-induced increase of the production of ICAM-1 from human endothelial cells. ConclusionsCadmium exposure was associated with future peripheral artery disease, supporting the concept that cadmium exposure in the population has proatherogenic effects, although ICAM-1 mediated effects do not seem to be involved.

Protease inhibitors and cardiac autonomic function in HIV-infected patients: a cross-sectional analysis from the Strategies for Management of Antiretroviral Therapy (SMART) Trial [RESEARCH]

Wed, 6 Mar 2013 00:00:00 +0000

ObjectiveTo compare cardiac autonomic function as measured by heart rate variability for HIV-infected participants taking protease inhibitors (PIs) with those taking a non-nucleoside reverse transcriptase inhibitor without a PI (NNRTI-no PI) regimen. DesignCross-sectional analysis. SettingMulticentre study. Participants2998 participants (average age 44 years, 28% females) enrolled in the Strategies for Management of Antiretroviral Therapy (SMART) trial. Primary outcome measuresHeart rate and two heart rate variability measures (the SD of all filtered RR intervals over the length of the recording (SDNN) and the root mean square of successive differences in normal RR intervals (rMSSD)). ResultsAt study entry, 869 participants were taking a boosted PI (PI/r), 579 a non-boosted PI and 1550 an NNRTI-no PI. Median values (IQR) of heart rate, SDNN and rMSSD were: 68 (60-75) beats/min (bpm), 21 (13-33) ms, 22 (13-35) ms in the PI/r group, 68 (60-75) bpm, 21 (13-33) ms and 21 (14-33) ms in the non-boosted PI group and 69 (62-77) bpm, 20 (13-31) ms and 21(13-33) ms in the NNRTI-no PI group. After adjustment for baseline factors, for those given PI/r and non-boosted PI, heart rate was 2.2 and 2.8 bpm, respectively, lower than the NNRTI-no PI group (p<0.001 for both). On the other hand, compared with the NNRTI-no PI group, log SDNN and log rMSSD were significantly greater for those in the non-boosted PI (p values for baseline adjusted differences in log-transformed SDNN and rMSSD were 0.004 and 0.001) but not for those in the PI/r group at the 0.01 -level. ConclusionsCompared to an NNRTI-no PI regimen, heart rate was lower for those taking a PI/r or non-boosted PI and heart rate variability was greater, reflecting better cardiac autonomic function, for those taking a non-boosted PI regimen but not PI/r.

An evaluation of the performance of the NHS Health Check programme in identifying people at high risk of developing type 2 diabetes [RESEARCH]

Tue, 5 Mar 2013 00:00:00 +0000

ObjectiveTo evaluate the performance of the National Health Service (NHS) Health Check in identifying people at high risk of having or developing type 2 diabetes. DesignRetrospective evaluation of the performance of the NHS Health Check diabetes filter (based on ethnicity, body mass index and blood pressure) in identifying people at risk for type 2 diabetes (glycated haemoglobin (HbA1c) [≥]42 mmol/mol recorded within 3 months of their NHS Health Check). SettingHeart of Birmingham Primary Care Trust (HoB PCT). Subjects34 022 patients with a Read code in the general practitioners' (GP) clinical record indicating that they had attended an NHS Health Check over the period April 2009 - February 2012. Outcome measuresPrimary outcome measure: proportion (%) of patients at risk of diabetes or non-diabetes hyperglycaemia not identified by a simple application of the NHS Health Check diabetes filter. Secondary outcome measures included sensitivity, positive predictive value (PPV) and specificity of the NHS Health Check diabetes filter. ResultsIn HoB PCT, the simple application of the NHS Health Check diabetes filter led to a failure to identify 1990/5968 (33.3% (95% CI, 31.2% to 35.4%)) of patients of known ethnicity at risk of having or developing diabetes (HbA1c[≥]42 mmol/mol). The NHS Health Check diabetes filter has a sensitivity of 66.8% (95% CI 65.7% to 68.0%), and the PPV was 41.1% (95% CI 40.1% to 42.1%). Specificity was 34.7% (95%CI 33.9% to 35.6%). Sensitivity and PPV of the NHS Health Check diabetes filter in the HoB PCT population are significantly greater for patients of Asian ethnic origin than for those of other ethnic backgrounds. ConclusionsThis evaluation, which was based on a large population sample, demonstrates that the NHS Health Check programme diabetes filter failed to identify a third of people at high risk of having or developing diabetes.

Protocol for an experimental study design to evaluate computer-enabled intervention to prevent and manage metabolic syndrome [PROTOCOL]

Fri, 1 Mar 2013 00:00:00 +0000

IntroductionThe rising prevalence of overweight and obesity has a direct correlation with increasing prevalence of hypertension, dyslipidaemia, type 2 diabetes, metabolic syndrome (MetS) and cardiovascular diseases. Most of the previous studies have been cross-sectional in nature and have looked at the prevalence of metabolic syndrome. Despite the clinical and public health importance of this phenomenon, not enough work has been carried out so far to study and remedy this situation. The objectives of the proposed study is to develop an innovative user-centred informatics platform that will facilitate delivery of a multifactorial intervention after taking into account user sociodemographics, health behaviour, prior disease state and knowledge attitudes and practices. ObjectiveThe objective of the proposed study is to develop an innovative user-centred informatics platform that will facilitate delivery of a multifactorial intervention after taking into account users' sociodemographics, health behaviour, prior disease state and knowledge, attitudes and behaviour. Methods and analysisA randomised two-group repeated-measures clinical trial design will be used, on 750 subjects from urban, rural and slum areas, in an Indian setting. The study participants will be randomly assigned to either the intervention (computer-based MetS Program, CBMP) or control (printed educational material, PEM) group. Both the groups will undergo screening, learning and evaluation assessments at the time of the visit and at follow-up visits 30, 60 and 90 days after the first visit. OutcomesThe outcomes expected in the intervention group include improvement in Mets-related knowledge, adherence to self-care practices, better quality of life and increased satisfaction with medical care. Ethics and disseminationThe study has been approved by the Institutional Review Board of Asian Institute of Public Health (IRB#621). The proposed study will also help us assess the usefulness and challenges of technology to disseminate health education among diverse users. Findings will be disseminated through peer-reviewed publications and national and international conference presentations to various stakeholders and local community health leaders. The ClinicalTrials.gov Identifier is NCT01713465.

The effect of integrated cardiac rehabilitation versus treatment as usual for atrial fibrillation patients treated with ablation: the randomised CopenHeartRFA trial protocol [PROTOCOL]

Wed, 20 Feb 2013 00:00:00 +0000

IntroductionAtrial fibrillation affects almost 2% of the population in the Western world. To preserve sinus rhythm, ablation is undertaken in symptomatic patients. Observational studies show that patients with atrial fibrillation often report a low quality of life and are less prone to be physically active due to fear of triggering fibrillation. Small trials indicate that exercise training has a positive effect on exercise capacity and mental health, and both patients with recurrent atrial fibrillation and in sinus rhythm may benefit from rehabilitation in managing life after ablation. No randomised trials have been published on cardiac rehabilitation for atrial fibrillation patients treated with ablation that includes exercise and psychoeducational components. AimTo test the effects of an integrated cardiac rehabilitation programme versus treatment as usual for patients with atrial fibrillation treated with ablation. Methods and analysis designThe trial is a multicentre parallel arm design with 1:1 randomisation to the intervention and control group with blinded outcome assessment. 210 patients treated for atrial fibrillation with radiofrequency ablation will be included. The intervention consists of a rehabilitation programme including four psychoeducative consultations with a specially trained nurse and 12 weeks of individualised exercise training, plus the standard medical follow-up. Patients in the control group will receive the standard medical follow-up. The primary outcome measure is exercise capacity measured by the VO2 peak. The secondary outcome measure is self-rated mental health measured by the Short Form 36 questionnaire. Postintervention, qualitative interviews will be conducted in 10% of the intervention group. Ethics and disseminationThe protocol is approved by the regional research ethics committee (number H-1-2011-135), the Danish Data Protection Agency (reg. nr. 2007-58-0015) and follows the latest version of the Declaration of Helsinki. The results will be published in peer-reviewed journals and may possibly impact on rehabilitation guidelines. Trial registrationClinicaltrials.gov identifier: NCT01523145.

A randomised controlled non-inferiority trial of primary care-based facilitated access to an alcohol reduction website (EFAR-FVG): the study protocol [PROTOCOL]

Tue, 12 Feb 2013 00:00:00 +0000

IntroductionThere is a strong body of evidence demonstrating the effectiveness of brief interventions by primary care professionals for risky drinkers. However, implementation levels remain low because of time constraints and other factors. Facilitated access to an alcohol reduction website offers primary care professionals a time-saving alternative to standard face-to-face intervention, but it is not known whether it is as effective. Methods and analysisA randomised controlled non-inferiority trial for risky drinkers comparing facilitated access to a dedicated website with standard face-to-face brief intervention to be conducted in primary care settings in the Region of Friuli Giulia Venezia, Italy. Adult patients will be given a leaflet inviting them to log on to a website to complete the Alcohol Use Disorders Identification Test (AUDIT-C) alcohol screening questionnaire. Screen positives will be requested to complete an online trial module including consent, baseline assessment and randomisation to either standard intervention by the practitioner or facilitated access to an alcohol reduction website. Follow-up assessment of risky drinking will be undertaken online at 1 month, 3 months and 1 year using the full AUDIT questionnaire. Proportions of risky drinkers in each group will be calculated and non-inferiority assessed against a specified margin of 10%. Assuming a reduction of 30% of risky drinkers receiving standard intervention, 1000 patients will be required to give 90% power to reject the null hypothesis. Ethics and disseminationThe protocol was approved by the Isontina Independent Local Ethics Committee on 14 June 2012. The findings of the trial will be disseminated through peer-reviewed journals, national and international conference presentations and public events involving the local administrations of the towns where the trial participants are resident. Registration detailsTrial registration number NCT: 01638338.

Is socioeconomic status associated with dietary sodium intake in Australian children? A cross-sectional study [RESEARCH]

Fri, 8 Feb 2013 00:00:00 +0000

ObjectiveTo assess the association between socioeconomic status (SES) and dietary sodium intake, and to identify if the major dietary sources of sodium differ by socioeconomic group in a nationally representative sample of Australian children. DesignCross-sectional survey. Setting2007 Australian National Children's Nutrition and Physical Activity Survey. ParticipantsA total of 4487 children aged 2-16 years completed all components of the survey. Primary and secondary outcome measuresSodium intake was determined via one 24 h dietary recall. The population proportion formula was used to identify the major sources of dietary salt. SES was defined by the level of education attained by the primary carer. In addition, parental income was used as a secondary indicator of SES. ResultsDietary sodium intake of children of low SES background was 2576 (SEM 42) mg/day (salt equivalent 6.6 (0.1) g/day), which was greater than that of children of high SES background 2370 (35) mg/day (salt 6.1 (0.1) g/day; p<0.001). After adjustment for age, gender, energy intake and body mass index, low SES children consumed 195 mg/day (salt 0.5 g/day) more sodium than high SES children (p<0.001). Low SES children had a greater intake of sodium from processed meat, gravies/sauces, pastries, breakfast cereals, potatoes and potato snacks (all p<0.05). ConclusionsAustralian children from a low SES background have on average a 9% greater intake of sodium from food sources compared with those from a high SES background. Understanding the socioeconomic patterning of salt intake during childhood should be considered in interventions to reduce cardiovascular disease.

Lifetime risk of developing coronary heart disease in Aboriginal Australians: a cohort study [RESEARCH]

Wed, 30 Jan 2013 00:00:00 +0000

ObjectivesLifetime risk of coronary heart disease (CHD) is an important yardstick by which policy makers, clinicians and the general public can assess and promote the awareness and prevention of CHD. The lifetime risk in Aboriginal people is not known. Using a cohort with up to 20 years of follow-up, we estimated the lifetime risk of CHD in Aboriginal people. DesignA cohort study. SettingA remote Aboriginal region. Participants1115 Aboriginal people from one remote tribal group who were free from CHD at baseline were followed for up to 20 years. Main outcome measuresDuring the follow-up period, new CHD incident cases were identified through hospital and death records. We estimated the lifetime risks of CHD with and without adjusting for the presence of competing risk of death from non-CHD causes. ResultsParticipants were followed up for 17 126 person-years, during which 185 developed CHD and 144 died from non-CHD causes. The average age at which the first CHD event occurred was 48 years for men and 49 years for women. The risk of developing CHD increased with age until 60 years and then decreased with age. Lifetime cumulative risk without adjusting for competing risk was 70.7% for men and 63.8% for women. Adjusting for the presence of competing risk of death from non-CHD causes, the lifetime risk of CHD was 52.6% for men and 49.2% for women. ConclusionsLifetime risk of CHD is as high as one in two in both Aboriginal men and women. The average age of having first CHD events was under 50 years, much younger than that reported in non-Aboriginal populations. Our data provide useful knowledge for health education, screening and prevention of CHD in Aboriginal people.

Methodology of a large prospective, randomised, open, blinded endpoint streamlined safety study of celecoxib versus traditional non-steroidal anti-inflammatory drugs in patients with osteoarthritis or rheumatoid arthritis: protocol of the standard care versus celecoxib outcome trial (SCOT) [PROTOCOL]

Tue, 29 Jan 2013 00:00:00 +0000

IntroductionCyclooxygenase 2 (COX-2) inhibitors have less upper gastrointestinal toxicity than traditional non-steroidal anti-inflammatory drugs (NSAIDs). However, both COX-2 inhibitors and traditional NSAIDs may be associated with adverse cardiovascular side effects. Data from randomised and observational studies suggest that celecoxib has similar cardiovascular toxicity to traditional NSAIDs. The overall safety balance of a strategy of celecoxib therapy versus traditional NSAID therapy is unknown. The European Medicines Agency requested studies of the cardiovascular safety of celecoxib within Europe. The Standard care versus Celecoxib Outcome Trial (SCOT) compares the cardiovascular safety of celecoxib with traditional NSAID therapy in the setting of the European Union healthcare system. Methods and analysisSCOT is a large streamlined safety study conducted in Scotland, England, Denmark and the Netherlands using the Prospective Randomised Open Blinded Endpoint design. Patients aged over 60 years with osteoarthritis or rheumatoid arthritis, free from established cardiovascular disease and requiring chronic NSAID therapy, are randomised to celecoxib or their previous traditional NSAID. They are then followed up for events by record-linkage within their normal healthcare setting. The hypothesis is non-inferiority with a confidence limit of 1.4. The primary endpoint is the first occurrence of hospitalisation or death for the Anti-Platelet Trialists' Collaboration (APTC) cardiovascular endpoint of non-fatal myocardial infarction, non-fatal stroke or cardiovascular death. Secondary endpoints are (1) first hospitalisation or death for upper gastrointestinal ulcer complications (bleeding, perforation or obstruction); (2) first occurrence of hospitalised upper gastrointestinal ulcer complications or APTC endpoint; (3) first hospitalisation for heart failure; (4) first hospitalisation for APTC endpoint plus heart failure; (5) all-cause mortality and (6) first hospitalisation for new or worsening renal failure. Ethics and disseminationSCOT has been approved by the relevant ethics committees. The trial results will be published in a peer-reviewed scientific journal. Clinical trials registration numberClinicaltrials.gov (NCT00447759).

A cohort study on psychosocial adjustment and psychopathology in adolescents and young adults with congenital heart disease [RESEARCH]

Mon, 28 Jan 2013 00:00:00 +0000

ObjectivesOur purpose was to study psychosocial adjustment and psychiatric morbidity of adolescents and young adults with congenital heart disease (CHD). DesignAll assessment measures were obtained on a single occasion. Clinical data was obtained through the patient's clinical records. SettingA teaching and tertiary care facility in Porto, Portugal. ParticipantsWe evaluated 110 CHD patients (62 male) aged from 12 to 26 years (mean=18.00{+/-}3.617), 58 cyanotic. All assessment measures were obtained on a single occasion in a tertiary hospital. Demographic information and clinical history were collected. Primary and secondary outcome measuresQuestionnaires regarded topics such as social support, family educational style, self-image and physical limitations, a standardised psychiatric interview Schedule for Affective Disorders and Schizophrenia--Lifetime version (SADS-L), and a self-report questionnaire on psychosocial adjustment, youth self-report or adult self-report. One of the relatives completed an observational version of the same questionnaire (child behaviour checklist (CBCL) or ABCL (adult behaviour checklist)). ResultsWe found a 21.8% lifetime prevalence of psychopathology, 31.3%, in females, 14.5% in males, showing a somewhat increased proneness in CHD patients. Females also showed worse psychosocial adjustment, with more somatic complaints (u=260 000; p=0.011), anxiety/depression (u=984 000; p=0.002), aggressive behaviour (u=920 500; p=0.001), attention problems (u=1123 500; p=0.027), thought problems (u=1069 500; p=0.010), internalisation (u=869 000; p=0.0) and externalisation (u=1163 000; p=0.05). Patients with severe CHD (u=939 000; p=0.03) and surgical repair (u=719 000; p=0.037) showed worse psychosocial adjustment. Those with poor social support showed more withdrawal (u=557 500; p=0.0) and social problems (u=748 500; p=0.023), and patients with unsatisfactory school performance revealed more anxiety/depression (u=916 000; p=0.02) and attention problems (u=861 500; p=0.007). ConclusionsCHD males with good social support and good academic performance have a better psychosocial adjustment.

Characteristics of people with low health literacy on coronary heart disease GP registers in South London: a cross-sectional study [RESEARCH]

Mon, 28 Jan 2013 00:00:00 +0000

ObjectiveTo explore characteristics associated with, and prevalence of, low health literacy in patients recruited to investigate the role of depression in patients on General Practice (GP) Coronary Heart Disease (CHD) registers (the Up-Beat UK study). DesignCross-sectional cohort. The health literacy measure was the Rapid Estimate of Health Literacy in Medicine (REALM). Univariable analyses identified characteristics associated with low health literacy and compared health service use between health literacy statuses. Those variables where there was a statistically significant/borderline significant difference between health literacy statuses were entered into a multivariable model. Setting16 General Practices in South London, UK. ParticipantsInclusion: patients >18 years, registered with a GP and on a GP CHD register. Exclusion: patients temporarily registered. Primary outcome measureREALM. ResultsOf the 803 Up-Beat cohort participants, 687 (85.55%) completed the REALM of whom 106 (15.43%) had low health literacy. Twenty-eight participants could not be included in the multivariable analysis due to missing predictor variable data, leaving a sample of 659. The variables remaining in the final model were age, gender, ethnicity, Indices of Multiple Deprivation score, years of education, employment; body mass index and alcohol intake, and anxiety scores (Hospital Anxiety and Depression Scale). Univariable analysis also showed that people with low health literacy may have more, and longer, practice nurse consultations than people with adequate health literacy. ConclusionsThere is a disadvantaged group of people on GP CHD registers with low health literacy. The multivariable model showed that patients with low health literacy have significantly higher anxiety levels than people with adequate health literacy. In addition, the univariable analyses show that such patients have more, and longer, consultations with practice nurses. We will collect 4-year longitudinal cohort data to explore the impact of health literacy in people on GP CHD registers and the impact of health literacy on health service use.

Cardiovascular and non-cardiovascular hospital admissions associated with atrial fibrillation: a Danish nationwide, retrospective cohort study [RESEARCH]

Thu, 24 Jan 2013 00:00:00 +0000

ObjectiveTo examine the excess risk of hospitalisation in patients with incident atrial fibrillation (AF). DesignA nationwide, retrospective cohort study. SettingDenmark. ParticipantsData on all admissions in Denmark from 1997 to 2009 were collected from nationwide registries. After exclusion of subjects previously admitted for AF, data on 4 602 264 subjects and 10 779 945 hospital admissions contributed to the study. Primary and secondary outcome measuresAge-stratified and sex-stratified admission rates were calculated for cardiovascular and non-cardiovascular admissions. Temporal patterns of readmission, relative risk and duration of frequent types of admission were calculated. ResultsOf 10 779 945 hospital admissions, 729 088(6.8%) were associated with AF. Admissions for cardiovascular reasons after 1, 3 and 6 months occurred for 6.0, 14.3 and 28.4% of AF patients versus 0.2, 0.6 and 1.8 of non-AF patients. Admissions for non-cardiovascular reasons after 1, 3 and 6 months comprised 6.8, 16.1 and 33.3% of AF patients and 1.2, 3.2 and 9.7% of non-AF patients. When stratified for age, AF was associated with similar cardiovascular admission rates across all age groups, while non-cardiovascular admission rates were higher in older patients. Within each age group and for both cardiovascular and non-cardiovascular admissions, AF was associated with higher rates of admission. When adjusted for age, sex and time period, patients with AF had a relative risk of 8.6 (95% CI 8.5 to 8.6) for admissions for cardiovascular reasons and 4.0 (95% CI 4.0 to 4.0) for admission for non-cardiovascular reasons. ConclusionsThis study confirms that the burden of AF is considerable and driven by both cardiovascular and non-cardiovascular admissions. These findings underscore the importance of using clinical and pharmacological means to reduce the hospital burden of AF in Western healthcare systems.

The TrueBlue model of collaborative care using practice nurses as case managers for depression alongside diabetes or heart disease: a randomised trial [RESEARCH]

Thu, 24 Jan 2013 00:00:00 +0000

ObjectivesTo determine the effectiveness of collaborative care in reducing depression in primary care patients with diabetes or heart disease using practice nurses as case managers. DesignA two-arm open randomised cluster trial with wait-list control for 6 months. The intervention was followed over 12 months. SettingEleven Australian general practices, five randomly allocated to the intervention and six to the control. Participants400 primary care patients (206 intervention, 194 control) with depression and type 2 diabetes, coronary heart disease or both. InterventionThe practice nurse acted as a case manager identifying depression, reviewing pathology results, lifestyle risk factors and patient goals and priorities. Usual care continued in the controls. Main outcome measureA five-point reduction in depression scores for patients with moderate-to-severe depression. Secondary outcome was improvements in physiological measures. ResultsMean depression scores after 6 months of intervention for patients with moderate-to-severe depression decreased by 5.7{+/-}1.3 compared with 4.3{+/-}1.2 in control, a significant (p=0.012) difference. (The plus-minus is the 95% confidence range.) Intervention practices demonstrated adherence to treatment guidelines and intensification of treatment for depression, where exercise increased by 19%, referrals to exercise programmes by 16%, referrals to mental health workers (MHWs) by 7% and visits to MHWs by 17%. Control-practice exercise did not change, whereas referrals to exercise programmes dropped by 5% and visits to MHWs by 3%. Only referrals to MHW increased by 12%. Intervention improvements were sustained over 12 months, with a significant (p=0.015) decrease in 10-year cardiovascular disease risk from 27.4{+/-}3.4% to 24.8{+/-}3.8%. A review of patients indicated that the study's safety protocols were followed. ConclusionsTrueBlue participants showed significantly improved depression and treatment intensification, sustained over 12 months of intervention and reduced 10-year cardiovascular disease risk. Collaborative care using practice nurses appears to be an effective primary care intervention. Trial registrationACTRN12609000333213 (Australia and New Zealand Clinical Trials Registry).

Effects of exenatide and liraglutide on heart rate, blood pressure and body weight: systematic review and meta-analysis [RESEARCH]

Thu, 24 Jan 2013 00:00:00 +0000

ObjectivesTo synthesise current evidence for the effects of exenatide and liraglutide on heart rate, blood pressure and body weight. DesignMeta-analysis of available data from randomised controlled trials comparing Glucagon-like peptide-1 (GLP-1) analogues with placebo, active antidiabetic drug therapy or lifestyle intervention. ParticipantsPatients with type 2 diabetes. Outcome measuresWeighted mean differences between trial arms for changes in heart rate, blood pressure and body weight, after a minimum of 12-week follow-up. Results32 trials were included. Overall, GLP-1 agonists increased the heart rate by 1.86 beats/min (bpm) (95% CI 0.85 to 2.87) versus placebo and 1.90 bpm (1.30 to 2.50) versus active control. This effect was more evident for liraglutide and exenatide long-acting release than for exenatide twice daily. GLP-1 agonists decreased systolic blood pressure by -1.79 mm Hg (-2.94 to -0.64) and -2.39 mm Hg (-3.35 to -1.42) compared to placebo and active control, respectively. Reduction in diastolic blood pressure failed to reach statistical significance (-0.54 mm Hg (-1.15 to 0.07) vs placebo and -0.50 mm Hg (-1.24 to 0.24) vs active control). Body weight decreased by -3.31 kg (-4.05 to -2.57) compared to active control, but by only -1.22 kg (-1.51 to -0.93) compared to placebo. ConclusionsGLP-1 analogues are associated with a small increase in heart rate and modest reductions in body weight and blood pressure. Mechanisms underlying the rise in heart rate require further investigation.

Direct treatment comparison of DAbigatran and RIvaroxaban versus NAdroparin in the prevention of venous thromboembolism after total knee arthroplasty surgery: design of a randomised pilot study (DARINA) [PROTOCOL]

Thu, 24 Jan 2013 00:00:00 +0000

IntroductionTwo novel agents, dabigatran and rivaroxaban, recently gained market authorisation for prevention of venous thromboembolism (VTE) after hip and knee arthroplasty. However, safety data of the new oral anticoagulants with a long-term use of 42 days are not available for total knee arthroplasty (TKA). Furthermore, there are no clinical trials comparing dabigatran and/or rivaroxaban with nadroparin, which is used in most Dutch departments of orthopaedic surgery. Our aim is to compare the 42-day use of dabigatran and rivaroxaban versus nadroparin after TKA in a clinical explorative pilot study by assessing the incidence of major bleeding and clinically relevant non-major bleeding using a standardised model of bleeding definitions. Methods and analysisA randomised open-label pilot study was conducted. Patients [≥]18 years and weighing more than 40 kg who were scheduled for a primary elective TKA were included. Patients were randomly assigned to three groups. Patients took either a daily oral dose of dabigatran etexilate 220 mg (n=50), 10 mg of oral rivaroxaban (n=50) or subcutaneous nadroparin 0.3 ml (n=50) for 42 days. The primary safety outcome measure was the incidence of bleeding events. Major bleeding events and clinically relevant non-major bleeding events were defined according to accepted guidelines. The secondary measures of this study were the occurrence of VTE, time until the bleeding event, compliance, duration of hospital stay, rehospitalisation, outpatient clinic visits and interventions following complications. Additionally, coagulation monitoring, knee flexion range of motion and Knee injury and Osteoarthritis Outcome Score were evaluated. DisseminationThe results of this trial provided insight into the validity of design for an adequately powered multicentre study investigating the safety of the new oral anticoagulants compared with nadroparin, an anticoagulant applied for prevention of VTE after knee arthroplasty in the Dutch situation. Trial registration numberClinicalTrials.gov: NCT01431456.

Early and intermediate survival after transcatheter aortic valve implantation: systematic review and meta-analysis of 14 studies [RESEARCH]

Fri, 11 Jan 2013 00:00:00 +0000

BackgroundTranscatheter aortic valve implants (TAVIs) is indicated as an alternative to surgical valve replacement for patients unfit for surgery. No systematic review has studied survival after 2 years and limited information is available on between-study heterogeneity. ObjectivesA systematic review and meta-analysis on intermediate survival after TAVI. Data sourcesPubMed, EMBASE, Scopus and references of selected articles. Study eligibility criteriaClinical studies evaluating TAVI, published between 2010 and 2012, reporting survival at 2 or more years. ParticipantsAbout 3500 patients from 14 studies. Study appraisal and synthesis methodsProportion meta-analysis with 95% CI and heterogeneity assessment (I2 and Cochran's Q). Meta-regression analysis was performed as well. ResultsPooled immediate postoperative death rate was 7.8% (95% CI 6.2% to 9.8%, I2=40.8%; Cochran's Q=97.7 with 92.9 df, p<0.0001) and stroke rate was 3.8% (95% CI 2.8% to 5.0%, I2=34.3%; Cochran's Q=96.5 with 92.9 df, p<0.0001). Pooled death rates at 1, 2 and 3 years were 23.2%, 31.0% and 38.6%, respectively. Among studies reporting on concomitant percutaneous coronary intervention, pooled death rates at 30 days, 1 year and 2 years were 6.3%, 17.8% and 25.8%, respectively. LimitationsAlthough our analysis examined a total of about 3500 patients, only a minority of these were actually followed up after 2 years. ConclusionsPooled survival rates after TAVI (at 2 years: 69.0%; at 3 years: 61.4%) can be considered excellent, particularly in the light of the high-risk profile of this patient population. Implications of key findingsThe favourable intermediate outcome in patients subjected to TAVI seems to justify its use in patients unfit for surgery. Such pooled results indicate that TAVI is a valid alternative to surgical valve replacement, but lack of data on late durability after TAVI prevents its use in low-risk patients with long expectancy of life.

Spatial variation of salt intake in Britain and association with socioeconomic status [RESEARCH]

Mon, 7 Jan 2013 00:00:00 +0000

ObjectivesTo evaluate spatial effects of variation and social determinants of salt intake in Britain. DesignCross-sectional survey. SettingGreat Britain. Participants2105 white male and female participants, aged 19-64 years, from the British National Diet and Nutrition Survey 2000-2001. Primary outcomesParticipants' sodium intake measured both with a 7-day dietary record and a 24-h urine collection. By accounting for important linear and non-linear risk factors and spatial effects, the geographical difference and spatial patterns of both dietary sodium intake and 24-h urinary sodium were investigated using Bayesian geo-additive models via Markov Chain Monte Carlo simulations. ResultsA significant north-south pattern of sodium intake was found from posterior probability maps after controlling for important sociodemographic factors. Participants living in Scotland had a significantly higher dietary sodium intake and 24-h urinary sodium levels. Significantly higher sodium intake was also found in people with the lowest educational attainment (dietary sodium: coeff. 0.157 (90% credible intervals 0.003, 0.319), urinary sodium: 0.149 (0.024, 0.281)) and in manual occupations (urinary sodium: 0.083 (0.004, 0.160)). These coefficients indicate approximately a 5%, 9% and 4% difference in average sodium intake between socioeconomic groups. ConclusionsPeople living in Scotland had higher salt intake than those in England and Wales. Measures of low socioeconomic position were associated with higher levels of sodium intake, after allowing for geographic location.

Differences between acute myocardial infarction and unstable angina: a longitudinal cohort study reporting findings from the Register of Information and Knowledge about Swedish Heart Intensive Care Admissions (RIKS-HIA) [RESEARCH]

Wed, 2 Jan 2013 00:00:00 +0000

ObjectivesThe aim of this study was to compare risk factors and comorbidities in patients with a first episode of acute coronary syndrome (ACS), being either acute myocardial infarction (AMI) or unstable angina pectoris (UAP). DesignCross-sectional and prospective. SettingThe Swedish population. ParticipantsA total of 145 346 consecutive patients aged 25-105 years included in the Swedish Register of Cardiac Intensive Care Admission (Register of Information and Knowledge about Swedish Heart Intensive Care) and admitted to hospital between 1 January 1996 and 30 June 2009 with a first episode of either AMI or UAP. Primary and secondary outcome measuresType of ACS and 1-year outcome. ResultsCompared with patients with UAP, AMI patients were more likely to be older; men; and former or current smokers; they were also more likely to have had diabetes and peripheral artery disease, but had lower rates of prior heart failure (HF) and fewer cardioprotective medications on admission. Among patients aged <65 years, 1.4% of men and 1.6% of women with UAP died within 1 year in 2003-2006 compared with 4.2% of men and 3.1% of women AMI patients (multiple-adjusted OR 3.54 (99% CI 2.29 to 5.48) in women and 2.65 (99% CI 2.11 to 3.34) in men). Corresponding proportions in patients aged [≥]65 years was 7.5% in men and 7.6% in women with UAP and 21.5% in men and 17.8% in women with AMI. ConclusionsIn patients with a first-time ACS episode, male sex, slightly older age, smoking, diabetes and peripheral arterial disease (PAD), but fewer cardioprotective medications, were major determinants for presenting with AMI. Despite increasingly active treatment in AMI and more inclusive diagnostic criteria in recent years, persistently worse prognosis was observed in AMI patients.

Clinical features of myocardial infarction and myocarditis in young adults: a retrospective study [RESEARCH]

Thu, 20 Dec 2012 00:00:00 +0000

ObjectivesTo evaluate the prevalence and clinical presentation of myocardial infarction (MI) and myocarditis in young adults presenting with chest pain (CP) and an elevated serum troponin I (TnI) to the emergency department (ED). DesignRetrospective, observational, single-centre study. ParticipantsAll consecutive patients 18-40 years old admitted to the ED for CP with an elevated TnI concentration. Primary outcome measuresPrevalence of MI, myocarditis and the characterisation of clinical presentation. Results1588 patients between 18 and 40 years old were admitted to the ED with CP during 30 consecutive months. 49 (3.1%) patients with an elevated TnI (>0.09 g/l) were included. 32.7% (16/49) were diagnosed with MI (11 ST-elevation myocardial infarction (STEMI) and 5 non-ST-elevation myocardial infarction (NSTEMI)) and 59.2% (29/49) with myocarditis. Compared with patients with myocarditis, MI patients were older (34.1{+/-}3.8 vs 26.9{+/-}6.4, p=0.0002) with more cardiovascular risk factors (mean 2.06 vs 0.69). Diabetes (18.8% vs 0%, p=0.0039), dyslipidaemia (56.2% vs 3.4%, p<0.0001) and family history of coronary artery disease (CAD) (37.5% vs 10.3% p=0.050) were associated with MI. Fever or recent viral illness were present in 75.9% (22/29) of patients with myocarditis, and in 0% of MI patients (p<0.0001). During follow-up, two patients with myocarditis were re-admitted for CP. ConclusionsIn this study, 32.7% of patients <40-year-old admitted to an ED with CP and elevated TnI had a diagnosis of MI. Key distinctive clinical factors include diabetes, dyslipidaemia, family history of CAD and fever or recent viral illness.

Home-based cardiac rehabilitation is an attractive alternative to no cardiac rehabilitation for elderly patients with coronary heart disease: results from a randomised clinical trial [RESEARCH]

Tue, 18 Dec 2012 00:00:00 +0000

ObjectiveTo compare home-based cardiac rehabilitation (CR) with usual care (control group with no rehabilitation) in elderly patients who declined participation in centre-based CR. DesignRandomised clinical trial with 12 months follow-up and mortality data after 5.5 years (mean follow-up 4[1/2] years). SettingRehabilitation unit, Department of Cardiology, Copenhagen, Denmark. ParticipantsElderly patients [≥]65 years with coronary heart disease. InterventionA physiotherapist made home visits in order to develop an individualised exercise programme that could be performed at home and surrounding outdoor area. Risk factor intervention, medical adjustment, physical and psychological assessments were offered at baseline and after 3, 6 and 12 months. Main outcome measurementsThe primary outcome was 6 min walk test (6MWT). Secondary outcomes were blood pressure, body composition, cholesterol profile, cessation of smoking, health-related quality of life (HRQoL), anxiety and depression. Results40 patients participated. The study population was characterised by high age (median age 77 years, range 65-92 years) and high level of comorbidity. Patients receiving home-based CR had a significant increase in the primary outcome 6MWT of 33.5 m (95% CI: 6.2 to 60.8, p=0.02) at 3 months, whereas the usual care group did not significantly improve, but with no significant differences between the groups. At 12 months follow-up, there was a decline in 6MWT in both groups; -55.2 m (95% CI: 18.7 to 91.7, p<0.01) in the home group and -52.1 m (95% CI: -3.0 to 107.1, p=0.06) in the usual care group. There were no significant differences in blood pressure, body composition, cholesterol profile, cessation of smoking or HRQoL after 3, 6 and 12 months follow-up. ConclusionsParticipation in home-based CR improved exercise capacity among elderly patients with coronary heart disease, but there was no significant difference between the home intervention and the control group. In addition, no significant difference was found in the secondary outcomes. When intervention ceased, the initial increase in exercise capacity was rapidly lost.

Obstructive airway disease and edentulism in the atherosclerosis risk in communities (ARIC) study [RESEARCH]

Tue, 18 Dec 2012 00:00:00 +0000

ObjectivesWe examined the potential association between prior chronic obstructive pulmonary disease (COPD) and edentulism, and whether the association varied by COPD severity using data from the Dental Atherosclerosis Risk in Communities Study. DesignCross-sectional. SettingCommunity dwelling subjects from four US communities. Participants and measurementsCases were identified as edentulous (without teeth) and subjects with one or more natural teeth were identified as dentate. COPD cases were defined by spirometry measurements that showed the ratio of forced expiratory volume (1 s) to vital capacity to be less than 0.7. The severity of COPD cases was also determined using a modified Global Initiative for Chronic Obstructive Lung Disease classification criteria (GOLD stage I-IV). Multiple logistic regression was used to examine the association between COPD and edentulism, while adjusting for age, gender, centre/race, ethnicity, education level, income, diabetes, hypertension, coronary heart disease and congestive heart failure, body mass index, smoking, smokeless tobacco use and alcohol consumption. Results13 465 participants were included in this analysis (2087 edentulous; 11 378 dentate). Approximately 28.3% of edentulous participants had prior COPD compared with 19.6% among dentate participants (p<0.0001). After adjustment for potential confounders, we observed a 1.3 (1.08 to 1.62) and 2.5 (1.68 to 3.63) fold increased risk of edentulism among GOLD II and GOLD III/IV COPD, respectively, as compared with the non-COPD/dentate referent. Given the short period of time between the measurements of COPD (visit 2) and dentate status (visit 4) relative to the natural history of both diseases, neither temporality nor insight as to the directionality of the association can be ascertained. ConclusionsWe found a statistically significant association between prior COPD and edentulism, with evidence of a positive incremental effect seen with increasing GOLD classification.

Representativeness of the dabigatran, apixaban and rivaroxaban clinical trial populations to real-world atrial fibrillation patients in the United Kingdom: a cross-sectional analysis using the General Practice Research Database [RESEARCH]

Fri, 14 Dec 2012 00:00:00 +0000

ObjectiveThree oral anticoagulants have reported study results for stroke prevention in patients with atrial fibrillation (AF) (dabigatran etexilate, rivaroxaban and apixaban); all demonstrated superiority or non-inferiority compared with warfarin (RE-LY, ARISTOTLE and ROCKET-AF). This study aimed to assess the representativeness for the real-world AF population, particularly the population eligible for anticoagulants. DesignA cross-sectional database analysis. SettingDataset derived from the General Practice Research Database (GPRD). Primary and secondary outcomes measureThe proportion of real-world patients with AF who met the inclusion/exclusion criteria for RE-LY, ARISTOTLE and ROCKET-AF were compared. The results were then stratified by risk of stroke using CHADS2 and CHA2DS2-VASc. Results83 898 patients with AF were identified in the GPRD. For the population at intermediate or high risk of stroke and eligible for anticoagulant treatment (CHA2DS2-VASc [≥]1; n=78 783 (94%)), the proportion eligible for inclusion into RE-LY (dabigatran etexilate) was 68% (95% CI 67.7% to 68.3%; n=53 640), compared with 65% (95% CI 64.7% to 65.3%; n=51 163) eligible for ARISTOTLE (apixaban) and 51% (95% CI 50.7% to 51.4%; n=39 892) eligible for ROCKET-AF (rivaroxaban). Using the CHADS2 method of risk stratification, for the population at intermediate or high risk of stroke and eligible for anticoagulation treatment (CHADS2 [≥]1; n=71 493 (85%)), the proportion eligible for inclusion into RE-LY was 74% (95% CI 73.7% to 74.3%; n=52 783), compared with 72% (95% CI 71.7% to 72.3%; n=51 415) for ARISTOTLE and 56% (95% CI 55.6% to 56.4%; n=39 892) for ROCKET-AF. ConclusionsPatients enrolled within RE-LY and ARISTOTLE were more reflective of the real-world' AF population in the UK, in contrast with patients enrolled within ROCKET-AF who were a more narrowly defined group of patients at higher risk of stroke. Differences between trials should be taken into account when considering the applicability of findings from randomised clinical trials. However, assessing representativeness is not a substitute for assessing generalisibility, that is, how well clinical trial results would translate into effectiveness and safety in everyday routine care.

Assessing the knowledge of sudden unexpected death in the young among Canadian medical students and recent graduates: a cross-sectional study [RESEARCH]

Fri, 14 Dec 2012 00:00:00 +0000

ObjectiveTo determine the level of knowledge concerning Sudden Unexpected Death in the Young (SUDY) among Canadian medical students and recent graduates ([≤]5 years after graduating). DesignA cross-sectional study was conducted by distributing a standardised, multiple choice, online questionnaire which assessed basic knowledge of SUDY. SettingCanadian medical schools and residency training programmes. Participants614 Canadian medical students (in either their penultimate or final year) and recent graduates ([≤]5 years after graduating) completed an anonymous online questionnaire. Primary and secondary outcome measuresThe level of knowledge regarding molecular aetiology, clinical presentation, pharmacological management and modes of inheritance of six of the commonest conditions causing SUDY, including hypertrophic cardiomyopathy (HCM), arrhythmogenic right ventricular cardiomyopathy (ARVC), Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia (CPVT), long QT syndrome (LQT) and Wolff-Parkinson White syndrome (WPW), were compared between medical students and recent graduates. Questions were broken down into basic knowledge and advanced categories and analysed as a secondary outcome measure. ResultsOf 614 responses, approximately two-thirds were answered by recent graduates, who generally scored 10% higher on all subject categories than medical students. Overall, questions regarding HCM were best answered (40%), followed by WPW syndrome (32%), CPVT (30%), ARVC (23%), Brugada syndrome (21%) and LQT syndrome (17%). Questions categorised as basic knowledge were answered 30% and 39% correctly in medical student and recent graduate groups, respectively, and those in the advanced category were answered 20% and 25% correctly. ConclusionsSurvey respondents fared poorly when answering questions regarding SUDY, which may be a reflection of inadequate medical education regarding these disorders. Standardised teaching regarding SUDY needs to occupy a stronger focus in Canadian medical curricula in order to prevent more unnecessary deaths by these syndromes in the future.

Predictors of cardiovascular events in a contemporary population with impaired glucose tolerance: an observational analysis of the Nateglinide and Valsartan in impaired glucose tolerance outcomes research (NAVIGATOR) trial [RESEARCH]

Wed, 12 Dec 2012 00:00:00 +0000

ObjectivesRisk factors for cardiovascular events are well established in general populations and those with diabetes but have been sparsely studied in impaired glucose tolerance (IGT). We sought to identify predictors of (1) a composite cardiovascular outcome (cardiovascular death, non-fatal myocardial infarction and non-fatal stroke) and (2) cardiovascular death, among patients with IGT. DesignWe studied participants enrolled in the Nateglinide and Valsartan in Impaired Glucose Tolerance Outcomes Research (NAVIGATOR) trial. Predictors of cardiovascular events were identified in observational analyses. SettingClinical trial participants in 40 countries. Participants9306 participants with biochemically confirmed IGT at high risk of cardiovascular events participated in NAVIGATOR. Primary and secondary outcome measuresCox proportional hazard regression models were constructed using variables (demographic data, medical history, clinical features, biochemical results and ECG findings) recorded at baseline to identify variables associated with and predictive of cardiovascular events. ResultsOver 6.4 years, 639 (6.9%) participants experienced a cardiovascular event, and 244 (2.6%) cardiovascular death. While predictors of both outcomes included established risk factors such as existing cardiovascular disease, male gender, older age, current smoking status and higher low-density lipoprotein cholesterol, other variables such as reduced estimated glomerular filtration rate, previous thromboembolic disease, atrial fibrillation, higher urinary albumin/creatinine ratio and chronic obstructive pulmonary disease were also important predictors. Glycaemic measures were not predictive of cardiovascular events. c-Statistics for predicting cardiovascular events and cardiovascular death were 0.74 and 0.82, respectively. This compares with c-statistics for cardiovascular events and cardiovascular death of 0.65 and 0.71, respectively, using the classical Framingham risk factors of age, total cholesterol, high-density lipoprotein cholesterol, systolic blood pressure, treatment for hypertension and smoking status. ConclusionsThe most powerful independent predictors of cardiovascular events in IGT included both established risk factors and other variables excluding measures of glycaemia, allowing effective identification of high-risk individuals.

Relationship between baseline resting diastolic function and exercise capacity in patients with hypertrophic cardiomyopathy undergoing treadmill stress echocardiography: a cohort study [RESEARCH]

Wed, 12 Dec 2012 00:00:00 +0000

ObjectiveDiastolic dysfunction (DD) is often incriminated in the symptomatology of patients with hypertrophic cardiomyopathy (HCM), but with limited supporting data. This study sought to assess the relationship between baseline diastolic function and exercise capacity in patients with HCM. DesignRetrospective study. SettingTertiary referral centre from Cleveland, Ohio, USA. Participants695 consecutive patients with a diagnosis of HCM who underwent exercise stress echocardiography between 1996 and 2011. Primary and secondary outcome measuresDiastolic function was reassessed from the resting echocardiograms by two blinded board-certified cardiologists. Maximal metabolic equivalents (MET) were extracted from the records. Multivariate regression analysis was performed to determine independent predictors of METs achieved. ResultsOf 695 patients, 130 were excluded because of inability to assess diastolic function. There was no significant difference in maximal METs achieved between those excluded and included in the analysis (p=0.80). There were 495 remaining patients with a mean age (SD) of 50 (15) years, and 32% women among whom 102 (21%) had normal diastolic function, 243 (49%) stage 1 DD; 131 (26%) stage 2 DD and 19 (4%) stage 3 DD. Patients with advanced DD had lower maximal METs achieved compared with those with normal diastolic function (OR 3.18(1.96 to 5.14) for stage 1 versus normal, and 3.21(1.89 to 5.43) for stage [≥]2 versus normal, p<0.0001 for both). After adjustment for demographics, comorbidities, echocardiographic parameters and haemodynamics, baseline DD was not an independent predictor of maximal METs achieved. ConclusionsAlthough baseline DD is common in patients with HCM, it does not predict maximal METs achieved beyond traditional risk factors.

Using simple telehealth in primary care to reduce blood pressure: a service evaluation [RESEARCH]

Wed, 12 Dec 2012 00:00:00 +0000

ObjectivesThis service evaluation examines how efficiently an innovative, simple and interactive blood pressure (BP) management intervention improves BP control in general practice. DesignProspective service evaluation. SettingTen volunteer general practitioner (GP) practices in Stoke on Trent, UK. ParticipantsPractice staff identified 124 intervention patients and invited them to participate based on two inclusion criteria: (1) patient has chronic kidney disease (CKD) stages 3 or 4 with BP persistently >130/85 mm Hg or (2) patient is >50 years-old (without CKD stages 3-5) with BP persistently >140/90 mm Hg despite prescribed antihypertensive medication. Three selected hypertensive control patients per intervention patient underwent usual clinical care (n=364). InterventionsIntervention patients used Florence', a simple, interactive mobile phone texting service with BP management intervention for 3 months, or for less time if their BP became controlled. Patients measured their BP, text their readings to Florence, received an immediate automatic response and had results reviewed by their GP/practice nurse at least weekly. Main outcome measuresBaseline data including recent BP readings and medications were collected; similar information was obtained for 6 months for both control and intervention patients. Average BP readings and medication usage were determined. ResultsAt final data collection, five intervention patients had not yet completed the full programme. Control and intervention patients were well matched except that intervention patients had significantly greater baseline BP. Greatest BP reductions were among hypertensive intervention patients without CKD stages 3-5. Intervention patients had significantly more BP readings and more changes in medication over the 3-month data collection period. ConclusionsSimple telehealth is acceptable and effective in reducing patients' BP. In future, poorly controlled patients could be targeted to maximise BP reductions or broader use could improve diagnostic accuracy and accessibility for patients who struggle to regularly attend their GP surgery.

Synergistic prognostic values of cardiac sympathetic innervation with left ventricular hypertrophy and left atrial size in heart failure patients without reduced left ventricular ejection fraction: a cohort study [RESEARCH]

Fri, 30 Nov 2012 00:00:00 +0000

ObjectivesThis study tested whether cardiac sympathetic innervation assessed by metaiodobenzylguanidine (MIBG) activity has long-term prognostic value in combination with left ventricular hypertrophy (LVH) and left atrial size in heart failure (HF) patients without reduced left ventricular ejection fraction (LVEF). DesignA single-centre prospective cohort study. Setting/participantsWith primary endpoints of cardiac death and rehospitalisation due to HF progression, 178 consecutive symptomatic HF patients with 74% men, mean age of 56 years and mean LVEF of 64.5% were followed up for 80 months. The entry criteria consisted of LVEF more than 50%, completion of predischarge clinical evaluations including cardiac MIBG and echocardiographic studies and at least more than 1-year follow-up when survived. ResultsThirty-four patients with cardiac evens had larger left atrial dimension (LAD), increased LV mass index, reduced MIBG activity quantified as heart-to-mediastinum ratio (HMR) than did the others. Multivariable Cox analysis showed that LAD and HMR were significant predictors (HR of 1.080 (95% CI 1.00 to 1.16, p=0.044) and 0.107 (95% CI 0.01 to 0.61, p=0.012, respectively). Thresholds of HMR (1.65) and LAD (37 mm) were closely related to identification of high-risk patients. In particular, HMR was a significant determinant of cardiac events in both patients with and without LV hypertrophy. Reduced HMR with enlarged LAD or LV hypertrophy identified patients at most increased risk; overall log-rank value, 11.5, p=0.0032 for LAD and 17.5, p=0.0002, respectively. ConclusionsIn HF patients without reduced LV ejection fraction, impairment of cardiac sympathetic innervation is related to cardiac outcomes independently and synergistically with LA size and LV hypertrophy. Cardiac sympathetic innervation assessment can contribute to better risk-stratification in combination with evaluation of LA size and LV mass but is needed to be evaluated for establishing aetiology-based risk assessment in HF patients at increased risk.

Does prior coronary artery bypass surgery alter the gender gap in patients presenting with acute coronary syndrome? A 20-year retrospective cohort study [RESEARCH]

Wed, 28 Nov 2012 00:00:00 +0000

ObjectivesPrevious studies demonstrated women presenting with acute coronary syndrome (ACS) have poor outcomes when compared with men the gender gap phenomenon'. The impact of prior coronary artery bypass graft (CABG) on women presenting with ACS is unknown. We hypothesised that the gender gap is altered in ACS patients with prior CABG. The aim of this study was to evaluate patients presenting with ACS according to their gender and history of prior CABG. DesignRetrospective, observational (cohort) study. SettingData were collected from hospital-based registry of patients hospitalised with ACS in Doha, Qatar, from 1991 through 2010. The data were analysed according to their gender and history of prior CABG. ParticipantsA total of 16 750 consecutive patients with ACS were studied. In total, 693 (4.3%) patients had prior CABG; among them 125 (18%) patients were women. Primary and secondary outcome measuresComparisons of clinical characteristics, inhospital treatment, and outcomes, including inhospital mortality and stroke were made. ResultsWomen with or without prior CABG were older, less likely to be smokers, but more likely to have diabetes mellitus (DM), hypertension and renal impairment than men (p=0.001). Women were less likely to receive reperfusion and early invasive therapies. When compared with men, women without prior CABG carried higher inhospital mortality (11% vs 4.9%; p=0.001) and stroke rates (0.9% vs 0.3%; p=0.001). Female gender was independent predictor of poor outcome. Among prior CABG patients, despite the fact that women had worse baseline characteristics and were less likely to receive evidence-based therapy, there were no significant differences in mortality or stroke rates between the two groups. ConclusionsConsistent with the world literature, women presenting with ACS and without prior CABG had higher death rates compared with men. Patients with prior CABG had comparable death rates regardless of the gender status.

Varying uses of the ABCD2 scoring system in primary and secondary care: a qualitative study [RESEARCH]

Wed, 28 Nov 2012 00:00:00 +0000

ObjectivesTo explore the usage of the ABCD2 risk stratification score by general practitioners (GPs) and hospital staff during the referral of patients with suspected transient ischaemic attack (TIA) or minor stroke. DesignQualitative study using semistructured interviews. SettingNine general practices and two hospital sites in England (Birmingham and Cambridge). ParticipantsNine GPs and nine hospital staff (two consultants, four nurses, two ultrasonographers and one administrator). ResultsIn both sites, clinicians used a referral proforma based around the ABCD2 scoring system for a range of purposes including self-education, to assist emphasising urgency to the patient, as a referral pathway facilitator and as a diagnostic tool. Negative views of its role included potential medicolegal threats, that it was a barrier to appropriate care, and led to misdiagnoses. Despite having differing uses by different clinicians, the ABCD2 proforma was the central means of interprofessional communication in TIA referrals across both sites. ConclusionsUnderstanding how prediction rules are used in practice is key to determining their impact on processes of care and clinical outcomes. In practice, GPs and their colleagues use the ABCD2 score in subtly different ways and it functions as a boundary object' by both accommodating these multiple purposes, yet still successfully aiding communication between them.

A cross-sectional survey and service evaluation of simple telehealth in primary care: what do patients think? [RESEARCH]

Wed, 28 Nov 2012 00:00:00 +0000

ObjectiveTo determine the patient experience of using a simple telehealth strategy to manage hypertension in adults. DesignAs part of a pragmatic service evaluation, the acceptability of, satisfaction with and ease of use of a simple telehealth strategy was determined via text, cross-sectional questionnaire survey administered by telephone, case studies, discussion groups and informal feedback from practices. This simple telehealth approach required patients to take home blood pressure (BP) readings and text them to a secure server ( Florence') for immediate automatic analysis and individual healthcare professional review. Participants124 intervention patients who used the Florence system. Setting10 volunteer general practitioner's (GP) practices in Stoke on Trent, UK, with poor health and high levels of material deprivation took part. ResultsPatient satisfaction was high. In particular, patients found the system easy to use, were very satisfied about the feedback from their GP regarding their BP readings, found the advice sent via Florence useful and preferred to send BP readings using Florence rather than having to go to the practice monthly to get BP checked. Overall satisfaction with the system was 4.81/5.00 at week 13 of the programme. Other advantages of being enrolled with Florence were improved education about hypertension, a greater feeling of support and companionship and flexibility which allowed self-care to occur at a time that suited the patient rather than their practice. ConclusionsThis simple telehealth strategy for managing hypertension in the community was met with high levels of patient satisfaction and feelings of control and support. This management approach should thus be considered for widespread implementation for clinical management of hypertension and other long-term conditions involving monitoring of patients' bodily measurements and symptoms as a large number of meaningful readings can be obtained from many patients in a prompt, efficient, interactive and acceptable way.

Impact of immunodepression and moderate alcohol consumption on coronary and other arterial disease events in an 11-year cohort of HIV-infected patients on antiretroviral therapy [RESEARCH]

Fri, 23 Nov 2012 00:00:00 +0000

ObjectiveTo investigate the relationship between response to antiretroviral therapy (ART), alcohol use and occurrence of a major coronary or other arterial disease event (CADE) in HIV-infected individuals. DesignA cohort study. A Cox model was used to identify the correlates of a first occurrence of a major CADE. SettingThe French ANRS CO8 APROCO-COPILOTE cohort was set up in 1997 to study clinical progression and patient-reported outcomes (PRO) after initiating a protease inhibitor-containing ART. Clinical data were retrieved from medical records. Self-administered questionnaires collected data on PRO and behaviours, including alcohol use. ParticipantsMetabolic data were only available for a subgroup (n=675) of the study group (n=1154). Main outcome measuresMajor coronary or other arterial disease first event. ResultsOver the 11-year follow-up, 49 major CADE were observed, with an incidence rate (95% CI)=0.75(0.57 to 0.99) per 100 person-years. Immunodepression (CD4 cell count <200 cells/mm3) was associated with an increased risk of CADE (adjusted HR (95% CI)=2.52(1.15 to 5.48)) after adjustment for female gender (0.25(0.08 to 0.83)), age (1.07(1.04 to 1.10)) and smoking>20 cigarettes/day (4.19(2.17 to 8.11)). Moreover, individuals with moderate alcohol consumption ([≤]4(3) alcohol units (AU)/day for men(women)) had a lower risk of CADE (0.38(0.20 to 0.71)) than alcohol abstainers, although the risk for those drinking>4(3) AU/day for men(women) was not significantly different from this latter group. These associations remained valid after adjustment for metabolic disorders. No significant association with exposure to any specific antiretroviral was detected. ConclusionsIn the long term, absence of immunodepression and moderate alcohol consumption remain associated with a lower risk of a major CADE. Combined interventions to reduce CADE-risk-related behaviours including adherence counselling for assuring long-term immunological response to ART in HIV-infected individuals are now a clinical and public health priority.

Effects of enzyme replacement therapy in adult patients with Fabry disease on cardiac structure and function: a retrospective cohort study of the Fabry Munster Study (FaMuS) data [RESEARCH]

Wed, 21 Nov 2012 00:00:00 +0000

ObjectiveFabry disease (FD) is an X-linked inborn error of glycosphingolipid catabolism caused by deficient lysosomal -galactosidase A activity. Progressive accumulation of globotriaosylceramide and related glycosphingolipids in vascular endothelial lysosomes of the heart, kidneys and brain is responsible for the main disease manifestations. The aim of our study was to assess short-term and long-term effects of enzyme replacement therapy (ERT) on cardiac mass and function. DesignRetrospective cohort study. SettingHospital outpatient clinic. Participants40 FD patients (21 men, 19 women) receiving agalsidase {beta}-ERT. Outcome measuresThe focus at baseline and follow-up examinations was on structural, functional (Doppler-echocardiography) as well as electrical changes (ECG) and blood pressure. ResultsIn the Early Group, systolic and diastolic blood pressures significantly decreased. Left-ventricular (LV) also decreased; however, wall thickness and LV mass index showed no further increase. VE as an indicator for diastolic function significantly improved (64{+/-}21 vs 75{+/-}27 cm/s, p=0.038). There were no significant changes of ECG parameters. There were few relevant changes in the Late Group, albeit systolic blood pressure significantly decreased and QRS duration significantly increased. In conclusion, echocardiographic left-ventricular mass index, interventricular septum thickness, left-ventricular posterior wall, left-ventricular end-diastolic dimension) and diastolic function parameters are valuable for follow-up and guidance of therapy. ConclusionsThe primary positive impact of ERT appears to be an early effect after the start of therapy, and early initiation of ERT should be recommended.

A randomised clinical trial of comprehensive cardiac rehabilitation versus usual care for patients treated for infective endocarditis--the CopenHeartIE trial protocol [PROTOCOL]

Wed, 21 Nov 2012 00:00:00 +0000

IntroductionInfective endocarditis (IE) is among the most serious infectious diseases in the western world. Treatment requires lengthy hospitalisation, high-dosage antibiotic therapy and possible valve replacement surgery. Despite advances in treatment, the 1-year mortality remains at 20-40%. Studies indicate that patients experience persisting physical symptoms, diminished quality of life and difficulties returning to work up to a year postdischarge. No studies investigating the effects of rehabilitation have been published. We present the rationale and design of the CopenHeartIE trial, which investigates the effect of comprehensive cardiac rehabilitation versus usual care for patients treated for IE. Methods and analysisWe will conduct a randomised clinical trial to investigate the effects of comprehensive cardiac rehabilitation versus usual care on the physical and psychosocial functioning of patients treated for IE. The trial is a multicentre, parallel design trial with 1 : 1 individual randomisation to either the intervention or control group. The intervention consists of five psychoeducational consultations provided by specialised nurses and a 12-week exercise training programme. The primary outcome is mental health (MH) measured by the standardised Short Form 36 (SF-36). The secondary outcome is peak oxygen uptake measured by the bicycle ergospirometry test. Furthermore, a number of exploratory analyses will be performed. Based on sample size calculation, 150 patients treated for left-sided (native or prosthetic valve) or cardiac device endocarditis will be included in the trial. A qualitative and a survey-based complementary study will be undertaken, to investigate postdischarge experiences of the patients. A qualitative postintervention study will explore rehabilitation participation experiences. Ethics and disseminationThe study complies with the Declaration of Helsinki and was approved by the regional research ethics committee (no H-1-2011-129) and the Danish Data Protection Agency (no 2007-58-0015). Study findings will be disseminated widely through peer-reviewed publications and conference presentations. RegistrationClinicaltrials.gov identifier: NCT01512615.

Diagnostic value of patterns of symptoms and signs of heart failure: application of latent class analysis with concomitant variables in a cross-sectional study [RESEARCH]

Mon, 12 Nov 2012 00:00:00 +0000

ObjectiveThe diagnosis of heart failure (HF) requires a compatible clinical syndrome and demonstration of cardiac dysfunction by imaging or functional tests. Since individual symptoms and signs are generally unreliable and have limited value for diagnosing HF, the authors aimed to identify patterns of symptoms and signs, based on findings routinely collected in current clinical practice, and to evaluate their diagnostic value, taking into account the a priori likelihood of HF. DesignCross-sectional evaluation. Participants1115 community participants aged [≥]45 years from Porto, Portugal, in 2006-2008. Main outcomes measuresPatterns were identified by latent class analysis, using concomitant variables to predict class membership. Patterns used 11 symptoms/signs, covering dimensions of congestion and hypoperfusion. Sex, age, education, obesity, diabetes and history of myocardial infarction or HF were included as concomitants. ResultsBayesian information criteria supported a solution with three patterns: 10.1% of participants followed a pattern with symptoms of troubled breathing and signs of congestion (pattern 1), 27.8% a pattern characterised mainly by signs of congestion (pattern 2) and 62.1% were essentially asymptomatic (pattern 3); model fit was best when including concomitant variables. The likelihood ratio of patterns 1, 2 and 3 for left ventricular systolic dysfunction was 3.4, 1.1 and 0.6, and for left ventricular diastolic dysfunction 3.5, 1.4 and 0.5, respectively. ConclusionsThe use of concomitant variables can improve the diagnostic value of the symptoms and signs patterns and, consequently, improve the usefulness of the symptoms and signs for diagnosis and as an outcome measure. The potential for application in other settings of complex diagnoses is very high. These models were shown to be useful to standardise and quantify the probabilistic reasoning in clinical diagnosis, upon which decisions of further investigation and even treatment need to be made.

Blood pressure in different ethnic groups (BP-Eth): a mixed methods study [PROTOCOL]

Mon, 5 Nov 2012 00:00:00 +0000

IntroductionPeople of South Asian, African-Caribbean and Irish ethnicity are known to have worse cardiovascular outcomes than those from the white British group. While the reasons underpinning this are complex, the effect of hypertension is both significant and modifiable. In recent years, there has been increasing interest in and uptake of out-of-office' methods for blood pressure (BP) monitoring. However, guidance in this area has been largely based on research among the white population. This study aims to answer the following questions: (1) How often and in what ways does blood pressure (BP) monitoring occur and how does this differ between white and the above minority ethnic populations. (2) Are the thresholds for diagnosis of hypertension, and treatment targets in hypertension comparable for white British and minority ethnic populations using different measurement modalities: office blood pressure, ambulatory BP monitoring and home monitoring? (3) What preferences for BP measurement do people from white and minority ethnic populations have? Methods and analysisA mixed methods approach will be used including the following: (1) A postal survey sent to 8000 hypertensive and not-known-to-be-hypertensive people from all four ethnic groups will determine current patterns of BP monitoring. (2) A validation study will compare BP measurement by ambulatory monitoring with office standard measurement, office research measurement and home monitoring in 200 people from each of the ethnic groups concerned. (3) Focus groups organised by ethnicity and gender will gather qualitative data regarding patient preferences for and experiences of BP measurement in each of the given modalities. The data collected from these phases will be analysed appropriately in order to answer the above research questions. Ethics and disseminationEthical approval has been gained from the Black Country Research Ethics Committee: Ref 09/H1202/114. The results of this work will be disseminated via journal publication and conference presentation.

Can manual ability be measured with a generic ABILHAND scale? A cross-sectional study conducted on six diagnostic groups [RESEARCH]

Wed, 31 Oct 2012 00:00:00 +0000

ObjectivesSeveral ABILHAND Rasch-built manual ability scales were previously developed for chronic stroke (CS), cerebral palsy (CP), rheumatoid arthritis (RA), systemic sclerosis (SSc) and neuromuscular disorders (NMD). The present study aimed to explore the applicability of a generic manual ability scale unbiased by diagnosis and to study the nature of manual ability across diagnoses. DesignCross-sectional study. SettingOutpatient clinic homes (CS, CP, RA), specialised centres (CP), reference centres (CP, NMD) and university hospitals (SSc). Participants762 patients from six diagnostic groups: 103 CS adults, 113 CP children, 112 RA adults, 156 SSc adults, 124 NMD children and 124 NMD adults. Primary and secondary outcome measuresManual ability as measured by the ABILHAND disease-specific questionnaires, diagnosis and nature (ie, uni-manual or bi-manual involvement and proximal or distal joints involvement) of the ABILHAND manual activities. ResultsThe difficulties of most manual activities were diagnosis dependent. A principal component analysis highlighted that 57% of the variance in the item difficulty between diagnoses was explained by the symmetric or asymmetric nature of the disorders. A generic scale was constructed, from a metric point of view, with 11 items sharing a common difficulty among diagnoses and 41 items displaying a category-specific location (asymmetric: CS, CP; and symmetric: RA, SSc, NMD). This generic scale showed that CP and NMD children had significantly less manual ability than RA patients, who had significantly less manual ability than CS, SSc and NMD adults. However, the generic scale was less discriminative and responsive to small deficits than disease-specific instruments. ConclusionsOur finding that most of the manual item difficulties were disease-dependent emphasises the danger of using generic scales without prior investigation of item invariance across diagnostic groups. Nevertheless, a generic manual ability scale could be developed by adjusting and accounting for activities perceived differently in various disorders.

Cardiovascular risk factor management of myocardial infarction patients with and without diabetes in the Netherlands between 2002 and 2006: a cross-sectional analysis of baseline data [RESEARCH]

Wed, 31 Oct 2012 00:00:00 +0000

ObjectiveWe examined levels and trends in cardiovascular risk factors and drug treatment in myocardial infarction (MI) patients with and without diabetes. DesignCross-sectional analysis of baseline Alpha Omega Trial data, a randomised controlled trial. Setting32 hospitals in the Netherlands. ParticipantsIn total, we had 1014 MI patients with diabetes (74% men) and 3823 without diabetes (79% men) aged 60-80 years, analysed over the period 2002-2006. ResultsBetween 2002 and 2006, a significantly decreasing trend in the prevalence of obesity (-5%, ptrend=0.02) and in systolic blood pressure (BP) levels (-5 mm Hg, ptrend<0.0001) was demonstrated in non-diabetic patients, but not in diabetic patients. In 2006, obesity, mean systolic BP and serum triglyceride levels were significantly higher, whereas high-density lipoprotein cholesterol levels were lower in diabetic patients compared to those without. Prescription of antihypertensive drug (diabetic vs non-diabetic patients respectively, 95% vs 93%, p=0.08) and statin treatment were high (86% and 90%, p=0.11). ConclusionsA high proportion of MI patients with and without diabetes was similarly treated with cardiovascular drugs. In spite of high drug treatment levels, more adverse risk factors were found in patients with diabetes.

Adverse events related to intravenous antibiotic therapy: a prospective observational study in the treatment of infective endocarditis [RESEARCH]

Fri, 26 Oct 2012 00:00:00 +0000

ObjectiveThe goal of this prospective observational study was to identify adverse events (AEs) related to the use of intravenous access sites used for infective endocarditis (IE) treatment in a tertiary care hospital. DesignThis is an observational, analytical and prospective study on AEs resulting from the use of intravenous access sites in patients under antimicrobial treatment for IE. Patients enrolled in the International Collaboration on Endocarditis (ICE) study had their peripheral, short-term central catheters (CVC) and peripherally inserted central catheters (PICC) monitored for AEs. SettingTertiary care hospital for cardiac surgery in Rio de Janeiro, Brazil. PatientsPatients over 14 years of age, hospitalised in 2009 and 2010 with possible or definite criteria for IE by the modified Duke criteria were included. Main outcome measuresAEs related to intravenous catheters: erythema and infiltration, fever, obstruction, externalisation and blood stream infection. ResultsThirty-seven episodes of IE in 35 patients were studied. Mean patient age was 44.32{+/-}15.2 years; 22 (63%) were men. The number of vascular catheters studied were 253, 148 of which were peripheral, 85 CVC (21 of which for haemodialysis) and 20 PICC. The most frequent AEs were erythema' and infiltration' for peripheral catheters, fever' for CVCs and obstruction' and externalisation' for PICCs. The number of catheter-days was 360 for peripheral catheters, 1.156 for CVC and 420 for PICC. Kaplan-Meier curves for CVC and PICC showed statistical difference for obstruction (p<0.001) in PICCs. More bacteraemia occurred in CVC compared with PICC. ConclusionsThe choice of intravenous access sites is critical in the treatment of IE. Close observation for AEs and stricter implementation of infection control measures and better manipulation of catheters are suggested.

The impact of drug eluting stents availability on the treatment choice among medical therapy, percutaneous or surgical revascularisation and on 4-year clinical outcome in patients with coronary artery disease: a cohort study [RESEARCH]

Fri, 26 Oct 2012 00:00:00 +0000

ObjectiveTo investigate the influence of the availability of drug eluting stents (DES) on treatment choice (TC) among medical therapy (MT), coronary by-pass surgery (CABG) or percutaneous coronary interventions (PCI) and the consequent clinical outcomes in patients hospitalised because of coronary artery disease (CAD). DesignObservational study comparing two cohorts hospitalised immediately before, and 3 years after DES availability. SettingThirteen hospitals with cardiology facilities. Patients2131 consecutive patients with at least one coronary stenosis >50% at coronary angiography (CA) after exclusion of those with acute myocardial infarction or previous CABG or associated relevant valvular disease. Main outcome measuresTreatment choice after CA and 4-year clinical outcomes. ResultsTC among MT (27% vs 29.2%), PCI (58.6% vs 55.5%) and CABG (14.5% vs 15.3%) was similar in the DES and bare metal stent (BMS) periods (p = 0.51). At least one DES was implanted in 57% of patients treated with PCI in 2005. After 4 years, no difference in mortality (13.8% vs 13.2%, p = 0.72), hospital admissions for myocardial infarction (6.6% vs 5.2%, p = 0.26), stroke (2.2% vs 1.7%, p = 0.49) and further revascularisations (22.3% vs 19.7%, p = 0.25) were observed in patients enrolled in the DES and BMS periods. Only in patients with Syntax score 23-32 a significant change of TC (p = 0.0002) occurred in the DES versus BMS period: MT in 17.4% vs 31%, PCI in 62.2% vs 35.8%, CABG in 20.3% vs 33.2%, with similar 4-year combined end-point of mortality, stroke, myocardial infarction and further revascularisations (45.3% vs 34.2%, p = 0.087). ConclusionsThree years after DES availability, the TC in patients with CAD has not changed significantly as well as the 4-year incidence of death, myocardial infarction, stroke and further revascularisations. In subgroup with Syntax score 23-32, a significant increase of indications to PCI was observed in the DES period, without any improvement of the 4-year clinical outcome.

Observational study on Takotsubo-like cardiomyopathy: clinical features, diagnosis, prognosis and follow-up [RESEARCH]

Fri, 26 Oct 2012 00:00:00 +0000

ObjectivesThe present study attempts to identify appropriate elements that may contribute to clarify the broad clinical features (diagnosis, care, complication and prognosis) of Takotsubo-like cardiomyopathy for improving its management. Design studyObservational study. SettingPrimary level of care referred to the emergency department of Vannini Hospital, Rome, Italy. ParticipantsThe study population consisted of 75 patients, 72 of the them were women and 3 were men with a mean age of 71.9{+/-}9.6 years. MethodsFrom February 2004 to November 2010, prospectively included 84 consecutive patients diagnosed for suspected Takotsubo-like cardiomyopathy. To be eligible, patients had to meet all the Mayo clinic criteria in the absence of neurological trauma or intracranial haemorrhage. Moreover, those patients that at follow-up still presented alteration of acute phase at ECG and echocardiogram were excluded. Thus, 75 patients comprised the study population. To follow-up 19 patients were lost. ResultsNone of 75 patients died in acute phase. All patients were promptly discharged (8.4{+/-}4.4 days), since they recovered their normal functional status without symptoms. Follow-up information was available for 56 patients. At a mean follow-up time of 2.2{+/-}2 years (range, 0.1-6.8 years) two octogenarian patients (2.6%) died because of sudden cardiac death and pulmonary embolism, respectively. The Takotsubo-like cardiomyopathy recurred in one patient. ConclusionsThe results of this study support the previous reports about the good prognosis, also in critically ill patients, of Takotsubo-like cardiomyopathy. Further assessment will be needed to determine a careful and sustained follow-up for choosing the best care and foreseeing the recurrences of this emerging condition.

Number and burden of cardiovascular diseases in relation to health-related quality of life in a cross-sectional population-based cohort study [RESEARCH]

Thu, 25 Oct 2012 00:00:00 +0000

ObjectivesTo clarify whether a greater number of cardiovascular diseases or a larger burden of disease are associated with poorer health-related quality of life (HRQoL) in an unselected general population. DesignA population-based cross-sectional postal survey. SettingsA random sample of the Swedish general population aged 40-79 years matched for national distributions of age, gender and region. ParticipantsOut of 6969 eligible individuals, 4910 (70.5%) participated. Primary and secondary measuresTo create a reference database for HRQoL outcomes in the general population. To assess certain diseases and their relation to HRQoL. MethodsPredefined cardiovascular diseases and HRQoL were assessed from validated questionnaires (EORTC QLQ-C30). Aspects of HRQoL included in the analyses were global quality of life, physical function, role function, emotional function, fatigue and dyspnoea. Individuals were categorised into: good function' versus poor function' and no or minor symptoms' versus symptomatic'. Multivariable logistic regression calculated OR with 95% CI for poor HRQoL. The exposures were the number of cardiovascular diseases and the subjective disease burden. ResultsOut of the 4910 participants, 1358 (28%) reported having a cardiovascular disease and hypertension was most common. Reporting a greater number of cardiovascular diseases was associated with an increased risk of poor HRQoL, especially regarding dyspnoea. The OR for symptomatic dyspnoea was 1.37 (95% CI 1.08 to 1.74) for participants with one cardiovascular disease, 4.81 (95% CI 3.24 to 7.13) for two diseases and 4.18 (95% CI 2.24 to 7.80) for those with three or more cardiovascular diseases. Among the 271 participants who assessed their cardiovascular disease burden as major, the highest risk for poor HRQoL was found for physical function (OR 6.18, 95% CI 3.72 to 10.30). ConclusionsIncreased number of cardiovascular diseases and a greater burden of disease are generally associated with poorer HRQoL in people with cardiovascular disease from an unselected population.

Ankle-Brachial Index determination and peripheral arterial disease diagnosis by an oscillometric blood pressure device in primary care: validation and diagnostic accuracy study [RESEARCH]

Thu, 25 Oct 2012 00:00:00 +0000

ObjectivesTo determine the level of agreement between a conventional' Ankle-Brachial Index (ABI) measurement (using Doppler and mercury sphygmomanometer taken by a research nurse) and a pragmatic' ABI measure (using an oscillometric device taken by a practice nurse) in primary care. To ascertain the utility of a pragmatic ABI measure for the diagnosis of peripheral arterial disease (PAD) in primary care. DesignCross-sectional validation and diagnostic accuracy study. Descriptive analyses were used to investigate the agreement between the two procedures using the Bland and Altman method to determine whether the correlation between ABI readings varied systematically. Diagnostic accuracy was assessed via sensitivity, specificity, accuracy, likelihood ratios, positive and negative predictive values, with ABI readings dichotomised and Receiver Operating Curve analysis using both univariable and multivariable logistic regression. SettingPrimary care in metropolitan and rural Victoria, Australia between October 2009 and November 2010. Participants250 persons with cardiovascular disease (CVD) or at high risk (three or more risk factors) of CVD. ResultsDespite a strong association between the two method's measurements of ABI there was poor agreement with 95% of readings within {+/-}0.4 of the 0.9 ABI cut point. The multivariable C statistic of diagnosis of PAD was 0.89. Other diagnostic measures were sensitivity 62%, specificity 92%, positive predictive value 67%, negative predictive value 90%, accuracy 85%, positive likelihood ratio 7.3 and the negative likelihood ratio 0.42. ConclusionsOscillometric ABI measures by primary care nurses on a population with a 22% prevalence of PAD lacked sufficient agreement with conventional measures to be recommended for routine diagnosis of PAD. This pragmatic method may however be used as a screening tool high-risk and overt CVD patients in primary care as it can reliably exclude the condition.

Rheumatic heart disease: pilot study for a population-based evaluation of prevalence and cardiovascular outcomes among schoolchildren in Nepal [RESEARCH]

Fri, 19 Oct 2012 00:00:00 +0000

ObjectivesTo evaluate a protocol for a population-based programme targeting the prevention of rheumatic heart disease (RHD) progression by early echocardiographic diagnosis of valvular lesions and timely implementation of secondary prevention. DesignObservational survey with a subsequent prospective cohort study. SettingPrivate boarding school in the urban area of the Sunsari district situated on the foothills of the Lower Himalayan Range in Eastern Nepal. ParticipantsFifty-four unselected school-going children 5-15 years of age, 24 girls and 30 boys. Primary outcome measureLogistic feasibility of a large-scale population-based screening study using the echocardiographic criteria formulated by the World Heart Federation, with longitudinal follow-up of children with definite or borderline RHD in a prospective cohort study. ResultsStandardised interview, physical examination and screening echocardiography were performed in a three-staged process and took approximately 6 min per child. Socio-economic status was assessed using surrogate markers such as the occupation of the primary caregiver, numbers of rooms at home, car, television, cell phone and internet connection. Physical examination was focused on cardiac auscultation and signs of acute rheumatic fever and targeted echocardiography was performed by an independent examiner without knowledge of the clinical findings. Two children with evidence of borderline RHD were re-examined at B.P. Koirala Institute of Health Sciences and the indication for secondary antibiotic prevention was discussed with the parents and the children. At 6 months of follow-up, echocardiographic findings were stable in both children. Implementation of secondary antibiotic prevention was challenged by impaired awareness of subclinical RHD among parents and inadequate cooperation with family physicians. ConclusionsThis pilot study shows that the methods outlined in the protocol can be translated into a large-scale population-based study. We learned that education and collaboration with teachers, parents and family physicians/paediatricians will be of key importance in order to establish a sustainable programme.

Development of an economic model to assess the cost-effectiveness of hawthorn extract as an adjunct treatment for heart failure in Australia [RESEARCH]

Sun, 14 Oct 2012 00:00:00 +0000

ObjectiveAn economic model was developed to evaluate the cost-effectiveness of hawthorn extract as an adjunctive treatment for heart failure in Australia. MethodsA Markov model of chronic heart failure was developed to compare the costs and outcomes of standard treatment and standard treatment with hawthorn extract. Health states were defined by the New York Heart Association (NYHA) classification system and death. For any given cycle, patients could remain in the same NYHA class, experience an improvement or deterioration in NYHA class, be hospitalised or die. Model inputs were derived from the published medical literature, and the output was quality-adjusted life years (QALYs). Probabilistic sensitivity analysis was conducted. The expected value of perfect information (EVPI) and the expected value of partial perfect information (EVPPI) were conducted to establish the value of further research and the ideal target for such research. ResultsHawthorn extract increased costs by $1866.78 and resulted in a gain of 0.02 QALYs. The incremental cost-effectiveness ratio was $85 160.33 per QALY. The cost-effectiveness acceptability curve indicated that at a threshold of $40 000 the new treatment had a 0.29 probability of being cost-effective. The average incremental net monetary benefit (NMB) was -$1791.64, the average NMB for the standard treatment was $92 067.49, and for hawthorn extract $90 275.84. Additional research is potentially cost-effective if research is not proposed to cost more than $325 million. Utilities form the most important target parameter group for further research. ConclusionsHawthorn extract is not currently considered to be cost-effective in as an adjunctive treatment for heart failure in Australia. Further research in the area of utilities is warranted.

Effects of myocardial fibrosis assessed by MRI on dynamic left ventricular outflow tract obstruction in patients with hypertrophic cardiomyopathy: a retrospective database analysis [RESEARCH]

Thu, 11 Oct 2012 00:00:00 +0000

BackgroundWhile implications of myocardial fibrosis on left ventricular (LV) function at rest have been studied in hypertrophic cardiomyopathy (HCM), the pathophysiological consequences on dynamic LV outflow tract (LVOT) gradient have so far not been investigated in detail. ObjectiveTo evaluate the influence of myocardial fibrosis, detected by MRI as late-gadolinium enhancement (LGE), on LVOT gradient in HCM. DesignRetrospective database analysis. SettingA single Italian cardiomyopathies referral centre. PatientsSeventy-six HCM patients with normal ejection fraction at rest. InterventionsPatients underwent cardiac MR and performed bicycle exercise echocardiogram within a month. ResultsLGE was present in 54 patients (71%), ranging from 0.2% to 32.4% of LV mass. There was a weak correlation between the amount of fibrosis and LVOT gradient variation during exercise in the overall population (r=-0.243, p=0.034) and a stronger correlation in patients with obstructive HCM at rest (r=-0.524, p=0.021). Patients with an LVOT gradient increase [≥]50 mm Hg during exercise had a significantly lesser extent of fibrosis than those with an increase <50 mm Hg (0.7% (IQR 0-2.4) vs 3.2% (IQR 0.2-7.4), p=0.006). The extent of fibrosis was significantly lower among the highest quartiles of LVOT gradient increase (p=0.009). ConclusionsIn patients with HCM and normal ejection fraction at rest, myocardial fibrosis was associated with a lower increase in LVOT gradient during exercise, probably due to a lesser degree of myocardial contractility recruitment. This negative association was more evident in patients with an obstructive form at rest.

Cost-effectiveness of a European preventive cardiology programme in primary care: a Markov modelling approach [RESEARCH]

Thu, 11 Oct 2012 00:00:00 +0000

ObjectiveTo investigate the longer-term cost-effectiveness of a nurse-coordinated preventive cardiology programme for primary prevention of cardiovascular disease (CVD) compared to routine practice from a health service perspective. DesignA matched, paired cluster-randomised controlled trial. SettingSix pairs of general practices in six countries. Participants1019 patients were randomised to the EUROACTION intervention programme and 1005 patients to usual care (UC) and who completed the 1-year follow-up. Outcome measuresEvidence on health outcomes and costs was based on patient-level data from the study, which had a 1-year follow-up period. Future risk of CVD events was modelled, using published risk models based on patient characteristics. An individual-level Markov model for each patient was used to extrapolate beyond the end of the trial, which was populated with data from published sources. We used an 11-year time horizon and investigated the impact on the cost-effectiveness of varying the duration of the effect of the intervention beyond the end of the trial. Results are expressed as incremental cost per quality-adjusted life-year gained. ResultsUnadjusted results found the intervention to be more costly and also more effective than UC. However, after adjusting for differences in age, gender, country and baseline risk factors, the intervention was dominated by UC, but this analysis was not able to take into account the lifestyle changes in terms of diet and physical activity. ConclusionsAlthough the EUROACTION study achieved healthier lifestyle changes and improvements in management of blood pressure and lipids for patients at high risk of CVD, compared to UC, it was not possible to show, using available risk equations which do not incorporate diet and physical activity, that the intervention reduced longer-term cardiovascular risk cost-effectively. Whether or not an intervention such as that offered by EUROACTION is cost-effective requires a longer-term trial with major cardiovascular events as the outcome. Trial Registration numberISRCTN 71715857.

Intensity versus duration of physical activity: implications for the metabolic syndrome. A prospective cohort study [RESEARCH]

Mon, 8 Oct 2012 00:00:00 +0000

ObjectivesTo explore the relative importance of leisure time physical activity (LTPA), walking and jogging on risk of developing the metabolic syndrome (MS). DesignA prospective cohort study. SettingThe Copenhagen City Heart Study. Participants10 135 men and women aged 21-98 years who attended an initial examination in 1991-1994 and were re-examined after 10 years. Outcome measuresThe association of LTPA, jogging, walking speed and walking volume with MS at baseline and at 10-year follow-up was investigated by multiple logistic regression analyses. ResultsBaseline prevalence of MS was 20.7% in women and 27.3% in men. In both women and men, MS prevalence was associated with lower LTPA and walking speed and was lower in joggers compared to non-joggers. In subjects free of MS at baseline, 15.4% had developed MS at 10-year follow-up. Risk of developing MS was reduced in subjects with moderate or high LTPA, higher walking speed and in joggers whereas a higher volume of walking was not associated with reduced risk. After multiple adjustment, odds ratio (OR) of developing MS in moderate/high LTPA was 0.71 (95% CI 0.50 to 1.01), fast walking speed 0.51 (0.33 to 0.80) and joggers 0.60 (0.37 to 0.95) and walking >1 h daily 1.22 (0.91 to 1.65). ConclusionsOur results confirm the role of physical activity in reducing MS risk and suggest that intensity more than volume of physical activity is important.

Coronary and mortality risk of novel oral antithrombotic agents: a meta-analysis of large randomised trials [RESEARCH]

Sat, 6 Oct 2012 00:00:00 +0000

ObjectiveOral direct thrombin and anti-Xa inhibitors have been shown to be efficacious in the prevention and treatment of venous thromboembolism, and prevention of embolic events in atrial fibrillation. Recent studies showed that dabigatran may be associated with increased rates of myocardial infarction (MI). Coronary risk for the other agents was unclear. The aim of the study is to determine the coronary risk among four novel antithrombotic agents. DesignMixed treatment comparison meta-analysis. Data sources and study selectionRandomised controlled trials (RCTs) on ximelagatran, dabigatran, rivaroxaban and apixaban were obtained from PubMed search (February 2012) and major scientific meeting in 2011. The random-effects model was used to evaluate the effect of these agents on MI or acute coronary syndrome (MI/ACS), major bleeding complication and all-cause mortality. ResultsFrom 28 RCTs (n=138 948), the risk for MI/ACS was higher for dabigatran (OR 1.30; 95% CI 1.04 to 1.63; p=0.021) but lower for rivaroxaban (OR 0.78; 95% CI 0.69 to 0.89; p<0.001). Ximelagatran showed a higher risk for MI/ACS, which was not statistically significant, while apixaban demonstrated a non-significant lower likelihood. Among the RCTs for MI/ACS among the four agents, only those pertaining to ximelagatran showed heterogeneity. Major bleeding complication rates varied considerably among different agents. Importantly, these agents were associated with a lower all-cause mortality, without heterogeneity among the studies. ConclusionsThe risk for coronary events was significantly higher for dabigatran but not significantly higher for ximelagatran. Conversely, this risk was lower among anti-Xa inhibitors. All-cause mortality was lower among those receiving novel antithrombotic agents. This information may be useful in selecting agents for specific subsets of patients requiring anticoagulation.

Does prognosis and socioeconomic status impact on trust in physicians? Interviews with patients with coronary disease in South Australia [RESEARCH]

Wed, 3 Oct 2012 00:00:00 +0000

ObjectivesThere is concern across a range of healthcare settings worldwide that trust in physicians is declining. Decreased trust may lead to lesser tolerance of prognosis uncertainty and an increased demand for tests, referrals and second opinions. Literature suggests that there has been a recent cultural shift towards decreased trust in, and increased questioning of, medical advice. We investigated the impact of varying prognosis and socioeconomic status (SES) on trust in physicians, and patient questioning of medical advice. DesignSemistructured, audio-recorded transcribed interviews were conducted. The interview schedule was developed with reference to the Health Belief Model. Interviews were conducted between October 2008 and September 2009. SettingParticipants were recruited via general practitioner clinics and hospital cardiac rehabilitation programmes. ParticipantsParticipants consisted of patients either receiving preventive treatment or active treatment for established cardiovascular disease. Outcome measuresA coding structure was developed based on the aim of the research, to investigate the impact of varying prognosis and SES on trust in physicians. ResultsOlder participants are more likely than their younger counterparts to be unquestioning of medical advice. Higher SES participants are more likely to question medical advice than lower SES participants. Also, unlike primary prevention participants, established pathology increased participants' trust, or decreased questioning behaviour. Participants who perceived themselves at risk of a poor or uncertain outcome were unlikely to doubt medical advice. ConclusionsBlind trust in physicians remains strong in older participants, participants who perceive their prognosis to be uncertain and a proportion of lower SES participants. This is important for practitioners in terms of patient agency and points to the importance of moral and ethical practice. However, physicians also need to be aware that there are a growing proportion of patients for whom trust needs to be developed, and cannot be assumed.

Use of cardiocerebral resuscitation or AHA/ERC 2005 Guidelines is associated with improved survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis [RESEARCH]

Wed, 3 Oct 2012 00:00:00 +0000

ObjectiveTo determine whether the use of cardiocerebral resuscitation (CCR) or AHA/ERC 2005 Resuscitation Guidelines improved patient outcomes from out-of-hospital cardiac arrest (OHCA) compared to older guidelines. DesignSystematic review and meta-analysis. Data sourcesMEDLINE, EMBASE, Web of Science and the Cochrane Library databases. We also hand-searched study references and consulted experts. Study selectionDesign: randomised controlled trials and observational studies. PopulationOHCA patients, age >17 years. Comparators Control' protocol versus Study' protocol. Control' protocol defined as AHA/ERC 2000 Guidelines for cardiopulmonary resuscitation (CPR). Study' protocol defined as AHA/ERC 2005 Guidelines for CPR, or a CCR protocol. OutcomeSurvival to hospital discharge. QualityHigh-quality or medium-quality studies, as measured by the Newcastle Ottawa Scale using predefined categories. ResultsTwelve observational studies met inclusion criteria. All the three studies using CCR demonstrated significantly improved survival compared to use of AHA 2000 Guidelines, as did five of the nine studies using AHA/ERC 2005 Guidelines. Pooled data demonstrate that use of a CCR protocol has an unadjusted OR of 2.26 (95% CI 1.64 to 3.12) for survival to hospital discharge among all cardiac arrest patients. Among witnessed ventricular fibrillation/ventricular tachycardia (VF/VT) patients, CCR increased survival by an OR of 2.98 (95% CI 1.92 to 4.62). Studies using AHA/ERC 2005 Guidelines showed an overall trend towards increased survival, but significant heterogeneity existed among these studies. ConclusionsWe demonstrate an association with improved survival from OHCA when CCR protocols or AHA/ERC 2005 Guidelines are compared to use of older guidelines. In the subgroup of patients with witnessed VF/VT, there was a threefold increase in OHCA survival when CCR was used. CCR appears to be a promising resuscitation protocol for Emergency Medical Services providers in increasing survival from OHCA. Future research will need to be conducted to directly compare AHA/ERC 2010 Guidelines with the CCR approach.

Does low-dose acetylsalicylic acid prevent cognitive decline in women with high cardiovascular risk? A 5-year follow-up of a non-demented population-based cohort of Swedish elderly women [RESEARCH]

Wed, 3 Oct 2012 00:00:00 +0000

ObjectiveThe aim of this study was to examine whether low-dose acetylsalicylic acid (ASA) influences the rate of cognitive change in elderly women. DesignProspective, population-based cohort study. SettingThe city of Gothenburg, Sweden, including those living in private households as well as in residential care. ParticipantsThe sample was derived from the Prospective Population Study of Women and from the H70 Birth Cohort Study in Gothenburg, Sweden. Both samples were obtained from the Swedish Population Register, based on birth date, and included 789 (response rate 71%) women aged 70-92 years. After the exclusion of individuals with dementia and users of warfarin, clopidogrel or heparin at baseline, 681 women were examined. Among all participants, 95.4% (N=601) had a high cardiovascular risk (CVD), defined as 10% or higher 10-year risk of any CVD event according to the Framingham heart study and 129 used low-dose ASA (75-160 mg daily) at baseline. After 5 years a follow-up was completed by 489 women. Primary outcome and secondary outcome measuresCognitive decline and dementia incidence in relation to the use of low-dose ASA and cardiovascular risk factors. Cognition was measured using the Mini Mental State Examination (MMSE), word fluency, naming ability and memory word tests. Dementia was diagnosed according to the DSM-III-R criterion. As secondary outcome incidence of stroke and peptic ulcer in relation to low-dose ASA use was studied. ResultsWomen on regular low-dose ASA declined less on MMSE at follow-up than those not on ASA. This difference was even more pronounced in those who had ASA at both examinations (p=0.004 compared with never users; n=66 vs n=338). All other cognitive tests showed the same trends. There were no differences between the groups regarding short-term risk for dementia (N=41). ConclusionLow-dose ASA treatment may have a neuroprotective effect in elderly women at high cardiovascular risk.

Preventing renal and cardiovascular risk by renal function assessment: insights from a cross-sectional study in low-income countries and the USA [RESEARCH]

Wed, 26 Sep 2012 00:00:00 +0000

ObjectiveTo assess the prevalence of microalbuminuria and kidney dysfunction in low-income countries and in the USA. DesignCross-sectional study of screening programmes in five countries. SettingScreening programmes in Nepal, Bolivia, the USA (National Health and Nutrition Examination Survey (NHANES) 2005-2008) Bangladesh and Georgia. ParticipantsGeneral population in Nepal (n=20 811), Bolivia (n=3436) and in the USA (n=4299) and high-risk subjects in Bangladesh (n=1518) and Georgia (n=1549). Primary and secondary outcome measuresEstimated glomerular filtration rate (eGFR)<60ml/min/1.73 m2 and microalbuminuria (defined as urinary albumin creatinine ratio values of 30-300 mg/g) were the main outcome measures. The cardiovascular (CV) risk was also evaluated on the basis of demographic, clinical and blood data. ResultsThe prevalence of eGFR<60ml/min/1.73 m2 was 19%, 3.2% and 7% in Nepal, Bolivia and the USA, respectively. In Nepal, 7% of subjects were microalbuminuric compared to 8.6% in the USA. The prevalence of participants with predicted 10-year CV disease (CVD) risk [≥]10% was 16.9%, 9.4% and 17% in Nepal, Bolivia and in the USA, respectively. In Bangladesh and Georgia, subjects with eGFR<60 ml/min/1.73 m2 were 8.6% and 4.9%, whereas those with microalbuminuria were 45.4% and 56.5%, respectively. Predicted 10-year CVD risk [≥]10% was 25.4% and 25% in Bangladesh and Georgia, respectively. ConclusionsRenal abnormalities are common among low-income countries and in the USA. Prevention programmes, particularly focused on those with renal abnormalities, should be established worldwide to prevent CVD and progression to end-stage renal disease.

Is admission blood glucose concentration a more powerful predictor of mortality after myocardial infarction than diabetes diagnosis? A retrospective cohort study [RESEARCH]

Tue, 25 Sep 2012 00:00:00 +0000

ObjectiveTo explore the relative association of admission blood glucose levels and antecedent diabetes on early and long-term survival in a contemporary UK population of patients with ST elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI). DesignRetrospective cohort study based on the Myocardial Ischaemia National Audit Project dataset. SettingTertiary care centre. Participants4111 (20.3% known diabetes) consecutive patients admitted with acute myocardial infarction (58.3% STEMI) between October 2002 and September 2008. Primary and secondary outcome measuresAll-cause mortality at 30 days and 1 year. The relative association of admission blood glucose and of antecedent diabetes with mortality was assessed using multivariate Cox regression analysis. Furthermore, we compared these relationships in patients with STEMI to those with NSTEMI. ResultsBy 30 days and 1 year, 409 (9.9%) and 677 (16.5%) of patients died. After adjusting for covariates, diabetes did not show independent association with mortality at any time point, in the entire cohort (HR 30 days 0.93 (95% CI 0.63 to 1.38); 1 year 1.00 (0.77 to 1.30)) or in subgroups of STEMI (HR 30 days 1.03 (0.65 to 1.64); 1 year 1.08 (0.77 to 1.51)) and NSTEMI (HR 30 days 0.62 (0.26 to 1.50); 1 year 0.87 (0.56 to 1.36)). In contrast, after adjusting for covariates, admission glucose showed robust and independent association with mortality in the entire cohort (HR: 30 days 1.07 (1.04 to 1.10); 1 year 1.05 (1.03 to 1.08)), and in the subgroup of STEMI (30 days 1.07 (1.03 to 1.10); 1 year 1.07 (1.04 to 1.10)), and NSTEMI (HR 30 days 1.07 (1.00 to 1.14); 1 year 1.02 (0.97 to 1.06)). ConclusionsAdmission glucose is strongly associated with mortality in all presentations of acute myocardial infarction (AMI), irrespective of established diabetes diagnosis. The increased risk is maintained up to 1 year. Future studies are required to assess the impact of active management of elevated blood glucose in improving mortality in individuals admitted with AMI.

Effectiveness of telemedicine and distance learning applications for patients with chronic heart failure. A protocol for prospective parallel group non-randomised open label study [PROTOCOL]

Tue, 25 Sep 2012 00:00:00 +0000

IntroductionChronic heart failure in Baltic Sea Region is responsible for more hospitalisations than all forms of cancer combined and is one of the leading causes of hospitalisations in elderly patients. Frequent hospitalisations, along with other direct and indirect costs, place financial burden on healthcare systems. We aim to test the hypothesis that telemedicine and distance learning applications is superior to the current standard of home care. Methods and analysisProspective parallel group non-randomised open label study in patients with New York Heart Association (NYHA) II-III chronic heart failure will be carried out in six Baltic Sea Region countries. The study is organised into two 6-month follow-up periods. The first 6-month period is based on active implementation of tele-education and/or telemedicine for patients in two groups (active run period) and one standard care group (passive run period). The second 6-month period of observation will be based on standard care model (passive run period) to all three groups. Our proposed practice change is based on translational research with empirically supported interventions brought to practice and aims to find the home care model that is most effective to patient needs. Ethics and disseminationThis study has been approved by National Bioethics Committee (2011-03-07; Registration No: BE-2-11). Trial RegistrationThis study has been registered in Australian New Zealand Clinical Trials Registry (ANZCTR) with registration number ACTRN12611000834954.

A trans European Union difference in the decline in trans fatty acids in popular foods: a market basket investigation [RESEARCH]

Mon, 17 Sep 2012 00:00:00 +0000

ObjectivesTo minimise the intake of industrial trans fatty acids (I-TFA) some countries have introduced labelling, while others have introduced legislative limits on the content of I-TFA in food. However, most countries still rely on food producers to voluntarily reduce the I-TFA content in food. The objective of the present study was to investigate the efficiency of these strategies in the EU. DesignThe potential consumption of I-TFA was assessed in a market basket investigation by analysing the I-TFA content in popular foods. SettingA standardised purchase methodology was used in 16 EU countries in 2005 and again in 2009. SamplesSeventy servings of French fries and chicken nuggets, 90 packages of microwave popcorn, and 442 samples of biscuits/cakes/wafers with partially hydrogenated vegetable fat' listed high on the list of ingredients were analysed. A high-trans menu was defined as a large serving of French fries and nuggets, 100 g of microwave popcorn and 100 g of biscuits/wafers/cakes. ResultsIn 2005, a high-trans menu provided above 30 g of I-TFA in five EU countries in Eastern Europe and 20-30 g in eight EU countries in Western Europe. In 2009 the values in Hungary, Poland and the Czech Republic remained high between 10 and 20 g, whereas they were less than 2 g in Germany, France and the UK. ConclusionsIn 2009 contents of I-TFA in popular foods in Western Europe appear low but, in spite of some reduction, still high in Eastern European EU countries. These findings suggest that millions of people in the EU still consume I-TFA in amounts that substantially increase their risk of coronary heart disease.

Impact of a reduced red and processed meat dietary pattern on disease risks and greenhouse gas emissions in the UK: a modelling study [RESEARCH]

Mon, 10 Sep 2012 00:00:00 +0000

ObjectivesConsumption of red and processed meat (RPM) is a leading contributor to greenhouse gas (GHG) emissions, and high intakes of these foods increase the risks of several leading chronic diseases. The aim of this study was to use newly derived estimates of habitual meat intakes in UK adults to assess potential co-benefits to health and the environment from reduced RPM consumption. DesignModelling study using dietary intake data from the National Diet and Nutrition Survey of British Adults. SettingBritish general population. MethodsRespondents were divided into fifths by energy-adjusted RPM intakes, with vegetarians constituting a sixth stratum. GHG emitted in supplying the diets of each stratum was estimated using data from life-cycle analyses. A feasible counterfactual UK population was specified, in which the proportion of vegetarians measured in the survey population doubled, and the remainder adopted the dietary pattern of the lowest fifth of RPM consumers. Outcome measuresReductions in risks of coronary heart disease, diabetes and colorectal cancer, and GHG emissions, under the counterfactual. ResultsHabitual RPM intakes were 2.5 times higher in the top compared with the bottom fifth of consumers. Under the counterfactual, statistically significant reductions in population aggregate risks ranged from 3.2% (95% CI 1.9 to 4.7) for diabetes in women to 12.2% (6.4 to 18.0) for colorectal cancer in men, with those moving from the highest to lowest consumption levels gaining about twice these averages. The expected reduction in GHG emissions was 0.45 tonnes CO2 equivalent/person/year, about 3% of the current total, giving a reduction across the UK population of 27.8 million tonnes/year. ConclusionsReduced consumption of RPM would bring multiple benefits to health and environment.

Public perceptions of coronary events risk factors: a discrete choice experiment [RESEARCH]

Tue, 4 Sep 2012 00:00:00 +0000

ObjectivesTo assess public perceptions of coronary heart disease (CHD) risk factors. DesignDiscrete choice experiment questionnaire. SettingSix provincial centres in Northern Ireland. Participants1000 adults of the general public in Northern Ireland. Primary and secondary outcomesThe general public's perception of CHD risk factors. The effect of having risk factor(s) on that perception. ResultsTwo multinomial logit models were created. One was a basic model (no heterogeneity permitted), while the other permitted heterogeneity based on respondents' characteristics. In both models individuals with very high cholesterol were perceived to be at the highest risk of having a coronary event. Respondents who reported having high cholesterol perceived the risk contribution of very high cholesterol to be greater than those who reported having normal cholesterol. Similar findings were observed with blood pressure and smoking. Respondents who were male and older perceived the contribution of age and gender to be lower than respondents who were female and younger. ConclusionsRespondents with different risk factors perceived such factors differently. These divergent perceptions of CHD risk factors could be a barrier to behavioural change. This brings into focus the need for more tailored health promotion campaigns to tackle CHD.

Myocardial performance assessment in neonates by one-segment strain and strain rate analysis by tissue Doppler - a quality improvement cohort study [RESEARCH]

Fri, 24 Aug 2012 00:00:00 +0000

ObjectivesTo investigate one-segment strain and strain rate indices as measures of myocardial performance in asphyxiated term neonates. DesignQuality improvement cohort study. SettingNewborns admitted to a neonatal intensive care unit at a Norwegian University Hospital for perinatal asphyxia and non-asphyxiated newborn recruited from the maternity ward at the same hospital. ParticipantsTwenty asphyxiated and 48 non-asphyxiated term neonates. Primary outcome measureStrain and strain rate indices and repeatability measures. One-segment longitudinal strain and strain rate by tissue Doppler were assessed on days 1, 2 and 3 of life in nine heart walls. Repeatability was compared against measurements from two-segment analyses previously performed in the same images. ResultsThe 95% limits of agreement were significantly better for the one-segment than two-segment repeatability analyses, the inter-rater peak systolic strain (PSS) was (-3.1, 3.3) vs (-11.4, 18.3)%, the inter-rater peak systolic strain rate (PSSR) was (-0.38, 0.40) vs (-0.79, 1.15)/s, the intra-rater PSS was (-2.5, 2.6) vs (-8.0, 9.8)% and the intra-rater PSSR was (-0.23, 0.25) vs (-0.75, 0.80)/s (p<0.05). The myocardial performance was lower in the asphyxiated neonates (indices closer to zero) than in the non-asphyxiated neonates, PSS was -17.8 (0.6) (mean (SEM)) vs -21.2 (0.3)%, PSSR -1.43 (0.08) vs -1.61 (0.03)/s, early diastolic strain rate 1.72 (0.11) vs 2.00 (0.11)/s and strain rate during the atrial systole 1.92 (0.17) vs 2.27 (0.10)/s (p<0.05), despite no difference in fractional shortening (29.0 (0.5) vs 29.1 (1.0)%) (p>0.05). ConclusionsOne-segment strain and strain rate assessed the reduced myocardial performance in asphyxiated neonates with significantly improved reproducibility as compared with two-segment analysis and was therefore more feasible than two-segment analyses for assessment of myocardial performance after perinatal asphyxia.