[Coronary risk and prescription in primary care patients with hypercholesterolemia]

The REGICOR-calibrated function provides a better classification of high-risk patients on statin treatment in the Spanish population than the Framingham or SCORE classifications

INTRODUCTION AND OBJECTIVES

To determine which cardiovascular risk function is best for classifying high-risk individuals on statins.

METHODS

Descriptive cross-sectional study of 804 randomly selected patients aged 35-74 years. Variables studied included statin treatment, high cardiovascular risk according to Framingham-REGICOR (10-year risk >or=10%), Framingham-Wilson (10-year risk >or=20%) and SCORE (10-year risk >or=5%) functions, age, sex, cardiovascular risk factors, and total and high-density lipoprotein (HDL) cholesterol.

RESULTS

Overall, 83 patients (10.3%) were taking statins. The prevalence of hypercholesterolemia was 25.6%. When high-risk patients were compared with low- and medium-risk patients, the SCORE function only found a significant difference in HDL-cholesterol level (difference, 5.1 mg/dl; P< .001), whereas the Framingham-REGICOR and Framingham-Wilson functions showed that hypercholesterolemia was more prevalent (at 41% and 37.8%, respectively), the total cholesterol level was higher (difference, 15 mg/dl and 12.5 mg/dl, respectively), and the HDL-cholesterol level was lower (difference, 11.9 mg/ dl and 12 mg/dl, respectively; all P< .001). The percentage of patients on statins classified as high-risk by each function was 16% for Framingham-REGICOR (odds ratio [OR]=1.81; 95% confidence interval [CI], 1.01-3.27), 13.4% for Framingham-Wilson (OR=1.47; 95% CI, 0.87-2.47) and 10.6% for SCORE (OR=1.09; 95% CI, 0.50-2.37). Statin use was also significantly associated with hypertension (OR=1.89; 95% CI, 1.20-2.99) and hypercholesterolemia (OR=11.01; 95% CI, 6.55-18.53), and inversely associated with age in patients <65 years (OR=0.51; 95% CI, 0.32-0.81).

CONCLUSIONS

The Framingham-REGICOR function was better at classifying high-risk patients on statins than the Framingham-Wilson or SCORE functions. Statin use was associated with hypercholesterolemia and hypertension and inversely with age in patients <65 years.

[Effectiveness of an intervention to improve quality care in reducing cardiovascular risk in hypertense patients]

OBJECTIVE

To evaluate the effectiveness of an intervention on health workers, based on quality improvement through reduction of cardiovascular risk in patients with hypertension.

DESIGN

Quasi-experimental study.

SETTING

Primary care. Two urban health centres.

PARTICIPANTS

A thousand hypertense patients selected by stratified random sampling. One centre (500) was assigned to implement a quality improvement intervention, while at the other centre (500) "usual care" procedures were followed (control group).

INTERVENTIONS

The quality improvement intervention consisted of a combined program designed for the medical and nursing staff that comprised audit, feedback, training sessions, and implementation of clinical practice guidelines.

MAIN MEASUREMENTS

Coronary risk using the Framingham scale and cardiovascular mortality risk using the SCORE project.

RESULTS

Absolute coronary risk decreased from 16.94% (95% CI, 15.92-17.66) to 13.81% (95% CI, 13.09-14.52) (P<.001) in the intervention group; whilst there was no significant change in the control group, which dropped from 17.63% (95% CI, 16.68-18.53) to 16.82% (95% CI, 15.91-17.74). The intervention led to a 2.28% point decrease (95% CI, 1.35-3.21) (P<.001) in coronary risk. Cardiovascular mortality risk decreased from 2.48% (95% CI, 2.35-2.62) to 2.19% (95% CI, 2.07-2.31) (P<.001) in the intervention group, with no significant change in the control group, which changed from 2.45% (95% CI, 2.30-2.59) to 2.52% (95% CI, 2.38-2.66). The intervention led to a 0.36% point decrease (95% CI, 0.05-0.73) (P<.001) in cardiovascular mortality risk.

CONCLUSIONS

The quality improvement intervention was effective in decreasing coronary risk and cardiovascular mortality risk in patients with hypertension.

[Appropriateness of lipid-lowering treatment and cardiovascular risk in patients with hypercholesterolemia]

OBJECTIVE

To assess the appropriateness of lipid-lowering treatment and to determine the clinical and epidemiological characteristics of patients with hypercholesterolemia.

METHOD

The study population comprised all the patients diagnosed with hypercholesterolemia in three urban health centres. A sample of 724 patients was obtained through a one-stage conglomerate method. A descriptive study was performed with two types of designs: retrospective and longitudinal, and cross-sectional. For the first we used the new Sheffield tables for cardiovascular risk; for the second, the Framingham categorical tables (Grundy).

RESULTS

Among patients in primary prevention, prescription of lipid-lowering therapy was appropriate in 44.2%. A total of 8.9% (SE = 1.1) of the patients aged 30-74 years in primary prevention had a high absolute risk (>/= 20% over 10 years). Six percent (0.8) had a high relative risk and 18.1% (2.0) had a moderately above-average risk.

CONCLUSIONS

More than the half of the patients were prescribed lipid-lowering treatment that was not indicated by risk tables. The current cardiovascular risk of our patients is satisfactory.

[Cholesterol is still high. So what do we do now? Treatment of uncontrolled hypercholesterolaemia over a year]

OBJECTIVE

To find the effectiveness of lipid-lowering treatment, based on normal clinical practice in primary care, on lipid control of patients with clear hypercholesterolaemia (HC). Design. Semi-experimental before-and-after intervention study.

SETTING

Urban health centre.

PARTICIPANTS

187 patients known to have lipaemia, with total or LDL cCholesterol (cLDL) above 270 and 190 mg/dl, respectively.Intervention. Normal clinical practice for twelve months in nine primary care clinics.

MAIN MEASUREMENTS

The lipid profile and lipid-lowering treatment were recorded at the start of the study and after twelve months. Lipid control (as a function of cLDL) was evaluated as optimal, acceptable or deficient, as a function of the cardiovascular risk, following the criteria of the Spanish Arteriosclerosis Society (1994).

RESULTS

In 27% of cases, no visit relating to HC was recorded by the patient s doctor. The number of patients treated with lipid-lowering drugs grew from 50 to 98 (27 vs 52%, p < 0,005), fundamentally at the expense of statin treatment. After twelve months, there were significant drops in the plasma concentration of cLDL (12%, 95%CI, 9 to 15%) and in the percentage of patients with deficient control, which fell from the initial 91% to 61% (p < 0.005), although only 16% reached optimal control.

CONCLUSIONS

After a year, under conditions of normal clinical practice, there was an increase in the use of lipid-lowering drugs and improvement in lipid control, though a bit over half the patients (61%) with clear hypercholesterolaemia maintained concentrations requiring treatment.

[Variation over two years of cardiovascular risk in patients cared for at primary care services for hypertension, diabetes and dyslipidemia]

OBJECTIVE

To analyse the modifications in cardiovascular risk in patients seen over two years in adult services for dyslipaemia, diabetes mellitus or hypertension.

DESIGN

Observational, retrospective study with repeated measurement tests.

SETTING

Two health centres.

PATIENTS

265 patients attended by the above services who were free of cardiovascular disease at the start of the study.

MEASUREMENTS AND RESULTS

During the study period, the cumulative incidence of cardiovascular morbidity was 4.2% (1.8-6.6%). Patients, without events, underwent a mean reduction in overall cardiovascular risk of -1.6% (p < 0.001). In patients classified as high-risk at the start of the study, the mean reduction was much greater: -3.7% (p < 0.001). Giving up smoking and controlling dyslipaemia brought about the greatest reductions in cardiovascular risk.

CONCLUSIONS

Monitoring of cardiovascular risk in patients attended for conditions in the INSALUD portfolio of services, i.e. hypertension, dyslipaemia, diabetes mellitus, enables this risk to be reduced and priority to be given to health care delivery to more vulnerable groups.