Applicability to primary care of national clinical guidelines on blood pressure lowering for people with stroke: cross sectional study

Applicability of Blood Pressure-Lowering Drug Trials to Real-World Patients With Cardiovascular Disease

This study aimed to assess applicability of blood pressure-lowering drug trials to real-world secondary preventive care. We applied the eligibility criteria of the landmark blood pressure-lowering drug trials (EUROPA, PEACE, HOPE-peripheral arterial disease [PAD], PRoFESS, and PROGRESS) to patients with coronary artery disease (CAD; n=5155), peripheral arterial disease (PAD; n=1487), and cerebrovascular disease (n=2515) participating in the UCC-SMART cohort. Baseline differences according to trial eligibility were assessed. Differences in risk of all-cause mortality and a composite of cardiovascular death, myocardial infarction, and stroke (major adverse cardiovascular event) were calculated using Cox proportional hazard models, adjusted for age, sex, and cardiovascular risk factors. Seventy-five percent of UCC-SMART patients with CAD would have been eligible for EUROPA, 84% for PEACE, 59% of patients with PAD for HOPE-PAD, 17% of patients with cerebrovascular disease for PRoFESS, and 100% for PROGRESS. Eligible patients were older (average difference ranging 1.4-14.6 years across trials). Eligible patients with CAD were at lower risk of major adverse cardiovascular event after adjustment for age, sex, and cardiovascular risk factors in PEACE (hazard ratio, 0.65 [95% CI, 0.53-0.79]) and of mortality in both EUROPA (hazard ratio, 0.72 [95% CI, 0.62-0.82]) and PEACE (0.63 [95% CI, 0.51-0.78]). Adjusted mortality and major adverse cardiovascular event risks were not different between eligible and ineligible patients with PAD and cerebrovascular disease in HOPE-PAD, PRoFESS, and PROGRESS. The majority of real-world patients with CAD, PAD, or cerebrovascular disease would be eligible for landmark trials on blood pressure-lowering drugs. Patients with CAD ineligible for the EUROPA and PEACE trials are at higher adjusted mortality and major adverse cardiovascular event risks, which may limit applicability of their results to ineligible patients.

A Gap in Post-Stroke Blood Pressure Target Attainment at Entry to Cardiac Rehabilitation

BACKGROUND

Recurrent events account for approximately one-third of all strokes and are associated with greater disability and mortality than first-time strokes. Blood pressure (BP) is the most important modifiable risk factor. Objectives were to determine the proportion of post-stroke patients enrolled in cardiac rehabilitation (CR) meeting systolic and diastolic BP (SBP/DBP) targets and to determine correlates of meeting these targets.

METHODS

A retrospective study of 1,804 consecutively enrolled post-stroke patients in a CR program was conducted. Baseline data (database records 2006-2017) included demographics, anthropometrics, clinical/medication history, and resting BP. Multivariate analyses determined predictors of achieving BP targets.

RESULTS

Mean age was 64.1 ± 12.7 years, median days from stroke 210 (IQR 392), with most patients being male (70.6%; n = 1273), overweight (66.8%; n = 1196), and 64.2% diagnosed with hypertension (n = 1159), and 11.8% (n = 213) with sleep apnea. A mean of 1.69 ± 1.2 antihypertensives were prescribed, with 26% (n = 469) of patients prescribed 3-4 antihypertensives. SBP target was met by 71% (n = 1281) of patients, 83.3% (n = 1502) met DBP target, and 64.3% (n = 1160) met both targets. Correlates of meeting SBP target were not having diabetes, younger age, fewer prescribed antihypertensives, and more recent program entry. Correlates of meeting DBP target were not having diabetes, older age, fewer prescribed antihypertensives, and more recent stroke.

CONCLUSIONS

Up to one-third of patients were not meeting BP targets. Patients with diabetes, and those prescribed multiple antihypertensives are at greater risk for poorly controlled SBP and DBP. Reasons for poor BP control such as untreated sleep apnea and medication non-adherence need to be investigated.

Primary care evidence in clinical guidelines: a mixed methods study of practitioners' views

BACKGROUND

Clinical practice guidelines are widely used in primary care, yet are not always based on applicable research.

AIM

To explore primary care practitioners' views on the applicability to primary care patients of evidence underpinning National Institute for Health and Care Excellence (NICE) guideline recommendations.

DESIGN AND SETTING

Delphi survey and focus groups in primary care, England, UK.

METHOD

Delphi survey of the perceived applicability of 14 guideline recommendations rated before and after a description of their evidence base, followed by two focus groups.

RESULTS

GPs significantly reduced scores for their perceived likelihood of pursuing recommendations after finding these were based on studies with low applicability to primary care, but maintained their scores for recommendations based on highly applicable research. GPs reported they were more likely to use guidelines where evidence was applicable to primary care, and less likely if the evidence base came from a secondary care population. Practitioners in the focus groups accepted that guideline developers would use the most relevant evidence available, but wanted clearer signposting of those recommendations particularly relevant for primary care patients. Their main need was for brief, clear, and accessible guidelines.

CONCLUSION

Guidelines should specify the extent to which the research evidence underpinning each recommendation is applicable to primary care. The relevance of guideline recommendations to primary care populations could be more explicitly considered at all three stages of guideline development: scoping and evidence synthesis, recommendation development, and publication. The relevant evidence base needs to be presented clearly and concisely, and in an easy to identify way.

Cost-effectiveness analysis of different systolic blood pressure targets for people with a history of stroke or transient ischaemic attack: Economic analysis of the PAST-BP study

BACKGROUND

The PAST-BP trial found that using a lower systolic blood pressure target (<130 mmHg or lower versus <140 mmHg) in a primary care population with prevalent cerebrovascular disease was associated with a small additional reduction in blood pressure (2.9 mmHg).

OBJECTIVES

To determine the cost effectiveness of an intensive systolic blood pressure target (<130 mmHg or lower) compared with a standard target (<140 mmHg) in people with a history of stroke or transient ischaemic attack on general practice stroke/transient ischaemic attack registers in England.

METHODS

A Markov model with a one-year time cycle and a 30-year time horizon was used to estimate the cost per quality-adjusted life year of an intensive target versus a standard target. Individual patient level data were used from the PAST-BP trial with regard to change in blood pressure and numbers of primary care consultations over a 12-month period. Published sources were used to estimate life expectancy and risks of cardiovascular events and their associated costs and utilities.

RESULTS

In the base-case results, aiming for an intensive blood pressure target was dominant, with the incremental lifetime costs being £169 lower per patient than for the standard blood pressure target with a 0.08 quality-adjusted life year gain. This was robust to sensitivity analyses, unless intensive blood pressure lowering reduced quality of life by 2% or more.

CONCLUSION

Aiming for a systolic blood pressure target of <130 mmHg or lower is cost effective in people who have had a stroke/transient ischaemic attack in the community, but it is difficult to separate out the impact of the lower target from the impact of more active management of blood pressure.

The Stroke Prevention Programme: a programme of research to inform optimal stroke prevention in primary care

Background

The management of cardiovascular (CV) risk factors in community populations is suboptimal. The aim of this programme was to explore the role of three approaches [use of a ‘polypill’; self-management of hypertension; and more intensive targets for blood pressure (BP) lowering after stroke] to improve prevention of CV disease (CVD) in the community.

Research questions

(1) Is it more cost-effective to titrate treatments to target levels of cholesterol and BP or to use fixed doses of statins and BP-lowering agents (polypill strategy)? (2) Will telemonitoring and self-management improve BP control in people on treatment for hypertension or with a history of stroke/transient ischaemic attack (TIA) in primary care and are they cost-effective? (3) In people with a history of stroke/TIA, can intensive BP-lowering targets be achieved in a primary care setting and what impact will this have on health outcomes and cost-effectiveness?

Design

Mixed methods, comprising three randomised controlled trials (RCTs); five cost-effectiveness analyses; qualitative studies; analysis of electronic general practice data; a screening study; a systematic review; and a questionnaire study.

Setting

UK general practices, predominantly from the West Midlands and the east of England.

Participants

Adults registered with participating general practices. Inclusion criteria varied from study to study.

Interventions

A polypill – a fixed-dose combination pill containing three antihypertensive medicines and simvastatin – compared with current practice and with optimal implementation of national guidelines; self-monitoring of BP with self-titration of medication, compared with usual care; and an intensive target for systolic BP of < 130 mmHg or a 10 mmHg reduction if baseline BP is < 140 mmHg, compared with a target of < 140 mmHg.

Results

For patients known to be at high risk of CVD, treatment as per guidelines was the most cost-effective strategy. For people with unknown CV risk aged ≥ 50 years, offering a polypill is cost-effective [incremental cost-effectiveness ratio (ICER) of £8115 per quality-adjusted life-year (QALY)] compared with a strategy of screening and treating according to national guidelines. Both results were sensitive to the cost of the polypill. Self-management in people with uncontrolled hypertension led to a 5.4 mmHg [95% confidence interval (CI) 2.4 to 8.5 mmHg] reduction in systolic BP at 1 year, compared with usual care. It was cost-effective for men (ICER of £1624 per QALY) and women (ICER of £4923 per QALY). In people with stroke and other high-risk groups, self-management led to a 9.2 mmHg (95% CI 5.7 to 12.7 mmHg) reduction in systolic BP at 1 year compared with usual care and dominated (lower cost and better outcome) usual care. Aiming for the more intensive BP target after stroke led to a 2.9 mmHg (95% CI 0.2 to 5.7 mmHg) greater reduction in BP and dominated the 140 mmHg target.

Conclusions

Potential for a polypill needs to be further explored in RCTs. Self-management should be offered to people with poorly controlled BP. Management of BP in the post-stroke population should focus on achieving a < 140 mmHg target.

Trial registration

Current Controlled Trials ISRCTN17585681, ISRCTN87171227 and ISRCTN29062286.

Funding

The National Institute for Health Research (NIHR) Programme Grants for Applied Research programme. Additional funding was provided by the NIHR National School for Primary Care Research, the NIHR Career Development Fellowship and the Department of Health Policy Research Programme.

Different systolic blood pressure targets for people with history of stroke or transient ischaemic attack: PAST-BP (Prevention After Stroke--Blood Pressure) randomised controlled trial

OBJECTIVE

To assess whether using intensive blood pressure targets leads to lower blood pressure in a community population of people with prevalent cerebrovascular disease.

DESIGN

Open label randomised controlled trial.

SETTING

99 general practices in England, with participants recruited in 2009-11.

PARTICIPANTS

People with a history of stroke or transient ischaemic attack whose systolic blood pressure was 125 mm Hg or above.

INTERVENTIONS

Intensive systolic blood pressure target (<130 mm Hg or 10 mm Hg reduction from baseline if this was <140 mm Hg) or standard target (<140 mm Hg). Apart from the different target, patients in both arms were actively managed in the same way with regular reviews by the primary care team.

MAIN OUTCOME MEASURE

Change in systolic blood pressure between baseline and 12 months.

RESULTS

529 patients (mean age 72) were enrolled, 266 to the intensive target arm and 263 to the standard target arm, of whom 379 were included in the primary analysis (182 (68%) intensive arm; 197 (75%) standard arm). 84 patients withdrew from the study during the follow-up period (52 intensive arm; 32 standard arm). Mean systolic blood pressure dropped by 16.1 mm Hg to 127.4 mm Hg in the intensive target arm and by 12.8 mm Hg to 129.4 mm Hg in the standard arm (difference between groups 2.9 (95% confidence interval 0.2 to 5.7) mm Hg; P=0.03).

CONCLUSIONS

Aiming for target below 130 mm Hg rather than 140 mm Hg for systolic blood pressure in people with cerebrovascular disease in primary care led to a small additional reduction in blood pressure. Active management of systolic blood pressure in this population using a <140 mm Hg target led to a clinically important reduction in blood pressure.Trial registration Current Controlled Trials ISRCTN29062286.

A review of clinical practice guidelines found that they were often based on evidence of uncertain relevance to primary care patients

Objectives

Primary care patients typically have less severe illness than those in hospital and may be overtreated if clinical guideline evidence is inappropriately generalized. We aimed to assess whether guideline recommendations for primary care were based on relevant research.

Study Design and Setting

Literature review of all publications cited in support of National Institute for Health and Care Excellence (NICE) recommendations for primary care. The relevance to primary care of all 45 NICE clinical guidelines published in 2010 and 2011, and their recommendations, was assessed by an expert panel.

Results

Twenty-two of 45 NICE clinical guidelines published in 2010 and 2011 were relevant to primary care. These 22 guidelines contained 1,185 recommendations, of which 495 were relevant to primary care, and cited evidence from 1,573 research publications. Of these cited publications, 590 (38%, range by guideline 6–74%) were based on patients typical of primary care.

Conclusion

Nearly two-third (62%) of publications cited to support primary care recommendations were of uncertain relevance to patients in primary care. Guideline development groups should more clearly identify which recommendations are intended for primary care and uncertainties about the relevance of the supporting evidence to primary care patients, to avoid potential overtreatment.

Do patients who take part in stroke research differ from non-participants? Implications for generalizability of results

BACKGROUND

Stroke is one of the most disabling neurological conditions. Clinical research is vital for expanding knowledge of treatment effectiveness among stroke patients. However, evidence begins to accumulate that stroke patients who take part in research represent only a small proportion of all stroke patients. Research participants may also differ from the broader patient population in ways that could potentially distort treatment effects reported in therapeutic trials. The aims of this study were to estimate the proportion of stroke patients who take part in clinical research studies and to compare demographic and clinical profiles of research participants and non-participants.

METHODS

5,235 consecutive patients admitted to the Stroke Care Unit of the Royal Melbourne Hospital, Melbourne, Australia, for stroke or transient ischaemic attack between January 2004 and December 2011 were studied. The study used cross-sectional design. Information was collected on patients' demographic and socio-economic characteristics, risk factors, and comorbidities. Associations between research participation and patient characteristics were initially assessed using χ(2) or Mann-Whitney tests, followed by a multivariable logistic regression analysis. The logistic regression analysis was carried out using generalised estimating equations approach, to account for patient readmissions during the study period.

RESULTS

558 Stroke Care Unit patients (10.7%) took part in at least one of the 33 clinical research studies during the study period. Transfer from another hospital (OR = 0.35, 95% CI 0.22-0.55), worse premorbid function (OR = 0.61, 95% CI 0.54-0.70), being single (OR = 0.61, 95% CI 0.44-0.84) or widowed (OR = 0.77, 95% CI 0.60-0.99), non-English language (OR = 0.67, 95% CI 0.53-0.85), high socio-economic status (OR = 0.74, 95% CI 0.59-0.93), residence outside Melbourne (OR = 0.75, 95% CI 0.60-0.95), weekend admission (OR = 0.78, 95% CI 0.64-0.94), and a history of atrial fibrillation (OR = 0.79, 95% CI 0.63-0.99) were associated with lower odds of research participation. A history of hypertension (OR = 1.50, 95% CI 1.08-2.07) and current smoking (OR = 1.23, 95% CI 1.01-1.50) on the other hand were associated with higher odds of research participation.

CONCLUSIONS

The results of this study indicate that stroke patients who take part in clinical research do not represent 'typical' patient admitted to a stroke unit. The imbalance of prognostic factors between stroke participants and non-participants has serious implications for interpretation of research findings reported in stroke literature. This study provides insights into clinical, demographic, and socio-economic characteristics of stroke patients that could potentially be targeted to enhance generalizability of stroke research studies. Given the imbalance of prognostic factors between research participants and non-participants, future studies need to examine differences in stroke outcomes of these groups of patients.

Five-year prognosis in an incident cohort of people presenting with acute myocardial infarction

BACKGROUND

Following an AMI, it is important for patients and their physicians to appreciate the subsequent risk of death, and the potential benefits of invasive cardiac procedures and secondary preventive therapy. Studies, to-date, have focused largely on high-risk populations. We wished to determine the risk of death in a population-derived cohort of 2,887 patients after a first acute myocardial infarction (AMI).

METHODS

Logistic regression and survival analysis were conducted to investigate the effect of different baseline characteristics, pharmacological therapies and revascularization procedures on coronary heart disease (CHD) and all-cause mortality outcomes.

RESULTS

Within five years 44.4% of patients died (27.1% short-term [<30 days] and 23.7% longer-term [≥30 days]). Percutaneous transluminal coronary angioplasty (Adjusted Hazards Ratio (AHR) = 0.49, 95% Confidence Interval (CI) 0.26-0.93), β-blockers (AHR = 0.58, 95%CI 0.46-0.74) and statins (AHR = 0.60, 95%CI 0.47-0.77) were all associated with significant reductions in longer-term CHD-related mortality. However, not all patients received secondary preventive therapy (8.7%). Diabetes (AHR = 1.83, 95%CI 1.43-2.34), stroke (AHR = 1.73, 95%CI 1.35-2.22), heart failure (AHR = 1.69, 95%CI 1.28-2.22), smoking (AHR = 1.72, 95%CI 1.18-2.51) and obesity (>30 kg/m2; AHR = 1.39, 95%CI 1.01-1.90) increased the risk of longer-term mortality independent of other risk factors.

CONCLUSIONS

It is encouraging that the coronary procedure PTCA and pharmacological secondary prevention therapies were found to be strongly associated with an important reduced risk of subsequent death, although not all patients received these interventions. Smoking, being obese and having cardiovascular related disease at baseline were also associated with an increased likelihood of longer-term mortality, independent of other baseline characteristics. Thus, the provision of smoking cessation, advice on diet (for obese patients) and optimal treatment is likely to be crucial for reducing mortality in all patients after AMI.

Heartwatch: the effect of a primary care-delivered secondary prevention programme for cardiovascular disease on medication use and risk factor profiles

BACKGROUND

Heartwatch is a secondary prevention programme of coronary heart disease (CHD) in primary care in Ireland. The aim was to further examine the effect of the Heartwatch programme on cardiovascular risk factors and treatments of patients with a follow-up of 3.5 years.

DESIGN

Prospective cohort study of 12,358 patients with established CHD (myocardial infarction, percutaneous cardiac intervention, coronary artery bypass graft) recruited by participating general practitioners; patients invited to attend on a quarterly basis, with continuing care implemented according to defined clinical protocols.

METHODS

Changes in risk factors and treatments at 1, 2, 3 and 3.5-year follow-up from baseline were made using paired t-test for continuous and McNemar's test for categorical data.

RESULTS

Important changes in systolic and diastolic blood pressure, total and low-density lipoprotein cholesterol and smoking status were observed at 1, 2, 3 and 3.5 years (P < 0.0001) with significant increase in proportions of patients within the target. However, changes in body mass index were small, with no significant improvement in waist circumference. There was a significant increase in prescription of secondary preventive medications and good patient compliance. Males were more likely to be within the target for systolic blood pressure, total cholesterol, waist circumference and exercise level at 3.5 years, but less likely for body mass index.

CONCLUSION

Studies of cardiac rehabilitation without any follow-up programmes show that over time patients revert in part to previous lifestyle habits; this primary care-delivered programme has shown sustained improvements in major risk factors, particularly smoking, blood pressure and cholesterol, and treatments for CHD. Weight management presents a greater challenge.

Current status of blood pressure management after stroke

Stroke is a leading cause of mortality and long-term disability in the western world, accounting for 5% of the UK health budget. Consequently, it has been the major focus of recent healthcare advances. Physiological disturbances are common following an acute stroke, chiefly blood pressure (BP) abnormalities (high and 'relatively' low BP), which indicate adverse prognosis. While pilot studies suggest that early intervention to moderate both extremes of BP may improve outcomes, definitive evidence is awaited from ongoing research. Long-term elevated BP is the most prevalent risk factor for future stroke, with a comprehensive evidence base supporting BP reduction to reduce the risk of vascular events, including stroke. However, adherence to secondary preventive medications, including antihypertensive agents, remains poor. This article summarizes the current understanding of the role of BP in stroke, focusing on the management of BP for secondary prevention. Further emphasis is placed on identifying deficiencies in long-term management; barriers to improved application and potential interventions to overcome these barriers are summarized.

Protocol for Past BP: a randomised controlled trial of different blood pressure targets for people with a history of stroke of transient ischaemic attack (TIA) in primary care

BACKGROUND

Blood pressure (BP) lowering in people who have had a stroke or transient ischaemic attack (TIA) leads to reduced risk of further stroke. However, it is not clear what the target BP should be, since intensification of therapy may lead to additional adverse effects. PAST BP will determine whether more intensive BP targets can be achieved in a primary care setting, and whether more intensive therapy is associated with adverse effects on quality of life.

METHODS/DESIGN

This is a randomised controlled trial (RCT) in patients with a past history of stroke or TIA. Patients will be randomised to two groups and will either have their blood pressure (BP) lowered intensively to a target of 130 mmHg systolic, (or by 10 mmHg if the baseline systolic pressure is between 125 and 140 mmHg) compared to a standard group where the BP will be reduced to a target of 140 mmHg systolic. Patients will be managed by their practice at 1-3 month intervals depending on level of BP and followed-up by the research team at six monthly intervals for 12 months.610 patients will be recruited from approximately 50 general practices. The following exclusion criteria will be applied: systolic BP <125 mmHg at baseline, 3 or more anti-hypertensive agents, orthostatic hypotension, diabetes mellitus with microalbuminuria or other condition requiring a lower treatment target or terminal illness.The primary outcome will be change in systolic BP over twelve months. Secondary outcomes include quality of life, adverse events and cardiovascular events.In-depth interviews with 30 patients and 20 health care practitioners will be undertaken to investigate patient and healthcare professionals understanding and views of BP management.

DISCUSSION

The results of this trial will inform whether intensive blood pressure targets can be achieved in people who have had a stroke or TIA in primary care, and help determine whether or not further research is required before recommending such targets for this population.

TRIAL REGISTRATION

ISRCTN29062286.

Considerable differences exist between prevalent and incident myocardial infarction cohorts derived from the same population

OBJECTIVE

Both prevalent and incident cohorts have been used in epidemiological and prognostic studies of ischemic heart disease (IHD). This study considers the differences between the cohort types.

STUDY DESIGN AND SETTING

Using linked primary care, secondary care, and death certification data, prevalent and incident cohorts of people with a first acute myocardial infarction (AMI) were formed from the same population. They were analyzed independently in terms of baseline characteristics and survival to revascularization, another AMI, or death.

RESULTS

55.7% of the prevalent cohort members were males, with a mean age of 71.0 years (standard deviation [SD]: 12.0). 59.0% of the incident cohort members were males, with a mean age of 64.7 years (SD: 13.3). Over 5 years, a greater proportion of prevalent cases died from any cause (31.4% [95% confidence interval(CI): 28.6-34.3]) and IHD (18.5% [95% CI: 16.2-21.0]) than incident cases (18.0% [95% CI: 15.0-21.4] and 12.2% [95% CI: 9.7-15.2], respectively). Mean time to death was shorter in prevalent cases. There was a small difference in the numbers of subsequent AMIs between cohorts. In the incident cohort, mean time to AMI was shorter. Fewer prevalent cases underwent coronary artery bypass grafting or percutaneous transluminal coronary angioplasty.

CONCLUSION

Considerable differences existed between the two cohorts in terms of baseline characteristics and prognosis. Incident cohorts derived from whole populations should be sought for estimation of survival.

Trials in primary care: statistical issues in the design, conduct and evaluation of complex interventions

Trials carried out in primary care typically involve complex interventions that require considerable planning if they are to be implemented successfully. The role of the statistician in promoting both robust study design and appropriate statistical analysis is an important contribution to a multi-disciplinary primary care research group. Issues in the design of complex interventions have been addressed in the Medical Research Council's new guidance document and over the past 7 years by the Royal Statistical Society's Primary Health Care Study Group. With the aim of raising the profile of statistics and building research capability in this area, particularly with respect to methodological issues, the study group meetings have covered a wide range of topics that have been of interest to statisticians and non-statisticians alike. The aim of this article is to provide an overview of the statistical issues that have arisen over the years related to the design and evaluation of trials in primary care, to provide useful examples and references for further study and ultimately to promote good practice in the conduct of complex interventions carried out in primary care and other health care settings. Throughout we have given particular emphasis to statistical issues related to the design of cluster randomised trials.

Service organisation for the secondary prevention of ischaemic heart disease in primary care

BACKGROUND

Ischaemic heart disease (IHD) is a major cause of mortality and morbidity and its prevalence is set to increase. Secondary prevention aims to prevent subsequent acute events in people with established IHD. While the benefits of individual medical and lifestyle interventions is established, the effectiveness of interventions which seek to improve the way secondary preventive care is delivered in primary care or community settings is less so.

OBJECTIVES

To assess the effectiveness of service organisation interventions, identifying which types and elements of service change are associated with most improvement in clinician and patient adherence to secondary prevention recommendations relating to risk factor levels and monitoring (blood pressure, cholesterol and lifestyle factors such as diet, exercise, smoking and obesity) and appropriate prophylactic medication.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2007, Issue 4), MEDLINE (1966 to Feb 2008), EMBASE (1980 to Feb 2008), and CINAHL (1981 to Feb 2008). Bibliographies were checked. No language restrictions were applied.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials of service organisation interventions in primary care or community settings in populations with established IHD.

DATA COLLECTION AND ANALYSIS

Analyses were conducted according to Cochrane recommendations and Odds Ratios (with 95% confidence intervals) reported for dichotomous outcomes, mean differences (with 95% CIs) for continuous outcomes.

MAIN RESULTS

Eleven studies involving 12,074 people with IHD were included. Increased proportions of patients with total cholesterol levels within recommended levels at 12 months, OR 1.90 (1.04 to 3.48), were associated with interventions that included regular planned appointments, patient education and structured monitoring of medication and risk factors, but significant heterogeneity was apparent. Results relating to blood pressure within target levels bordered on statistical significance. There were no significant effects of interventions on mean blood pressure or cholesterol levels, prescribing, smoking status or body mass index. Few data were available on the effect on diet. There was some suggestion of a "ceiling effect" whereby interventions have a diminishing beneficial effect once certain levels of risk factor management are reached.

AUTHORS' CONCLUSIONS

There is weak evidence that regular planned recall of patients for appointments, structured monitoring of risk factors and prescribing, and education for patients can be effective in increasing the proportions of patients within target levels for cholesterol control and blood pressure. Further research in this area would benefit from greater standardisation of the outcomes measured.

The inclusion of cognition in vascular risk factor clinical practice guidelines

BACKGROUND

People with vascular risk factors are at increased risk for cognitive impairment as well as vascular disease. The objective of this study was to evaluate whether vascular risk factor clinical practice guidelines consider cognition as an outcome or in connection with treatment compliance.

METHODS

Articles from PubMed, EMBASE, and the Cochrane Library were assessed by at least two reviewers and were included if: (1) Either hypertension, high cholesterol, diabetes, or atrial fibrillation was targeted; (2) The guideline was directed at physicians; (3) Adult patients (aged 19 years or older) were targeted; and (4) The guideline was published in English. Of 91 guidelines, most were excluded because they were duplicates, older versions, or focused on single outcomes.

RESULTS

Of the 20 clinical practice guidelines that met inclusion criteria, five mentioned cognition. Of these five, four described potential treatment benefits but only two mentioned that cognition may affect compliance. No guidelines adequately described how to screen for cognitive impairment.

CONCLUSION

Despite evidence that links cognitive impairment to vascular risk factors, only a minority of clinical practice guidelines for the treatment of vascular risk factors consider cognition as either an adverse outcome or as a factor to consider in treatment.

The impact of renal insufficiency and anaemia on survival in patients with cardiovascular disease: a cohort study

Background

The simultaneous occurrence of cardiovascular disease (CVD), kidney disease, and anaemia is associated with increased morbidity and mortality. In the community setting, little data exists about the risk associated with milder levels of anaemia when it is present concurrently with CVD and chronic kidney disease (CKD). The aim of this study was to establish the prevalence of CKD and anaemia in patients with CVD in the community and to examine whether the presence of anaemia was associated with increased morbidity and mortality.

Methods

This study was designed as a retrospective cohort study and involved a random sample of 35 general practices in the West of Ireland. A practice-based sample of 1,609 patients with established cardiovascular disease was generated in 2000/2001 and followed for five years. The primary endpoint was death from any cause. Statistical analysis involved using one-way ANOVA and Chi-squared tests for baseline data and Cox proportional-hazards models for mortality data.

Results

Of the study sample of 617 patients with blood results, 33% (n = 203) had CKD while 6% (n = 37) had CKD and anaemia. The estimated risk of death from any cause, when compared to patients with cardiovascular disease only, was almost double (HR = 1.98, 95% CI 0.99 to 3.98) for patients with both CVD and CKD and was over 4 times greater (HR = 4.33, 95% CI 1.76 to 10.68) for patients with CVD, CKD and anaemia.

Conclusion

In patients with cardiovascular disease in the community, chronic kidney disease and anaemia occur commonly. The presence of chronic kidney disease carries an increased mortality risk which increases in an additive way with the addition of anaemia. These results suggest that early primary care diagnosis and management of this high risk group may be worthwhile.

Five year prognosis in patients with angina identified in primary care: incident cohort study

OBJECTIVE

To ascertain the risk of acute myocardial infarction, invasive cardiac procedures, and mortality among patients with newly diagnosed angina over five years.

DESIGN

Incident cohort study of patients with primary care data linked to secondary care and mortality data.

SETTING

40 primary care practices in Scotland.

PARTICIPANTS

1785 patients with a diagnosis of angina as their first manifestation of ischaemic heart disease, 1 January 1998 to 31 December 2001.

MAIN OUTCOME MEASURES

Adjusted hazard ratios for acute myocardial infarction, coronary artery bypass grafting, percutaneous transluminal coronary angioplasty, death from ischaemic heart disease, and all cause mortality, adjusted for demographics, lifestyle risk factors, and comorbidity at cohort entry.

RESULTS

Mean age was 62.3 (SD 11.3). Male sex was associated with an increased risk of acute myocardial infarction (hazard ratio 2.01, 95% confidence interval 1.35 to 2.97), death from ischaemic heart disease (2.80, 1.73 to 4.53), and all cause mortality (1.82, 1.33 to 2.49). Increasing age was associated with acute myocardial infarction (1.04, 1.02 to 1.06, per year of age increase), death from ischaemic heart disease (1.09, 1.06 to 1.11, per year of age increase), and all cause mortality (1.09, 1.07 to 1.11, per year of age increase). Smoking was associated with subsequent acute myocardial infarction (1.94, 1.31 to 2.89), death from ischaemic heart disease (2.12, 1.32 to 3.39), and all cause mortality (2.11, 1.52 to 2.95). Obesity was associated with death from ischaemic heart disease (2.01, 1.17 to 3.45) and all cause mortality (2.20, 1.52 to 3.19). Previous stroke was associated with all cause mortality (1.78, 1.13 to 2.80) and chronic kidney disease with death from ischaemic heart disease (5.72, 1.74 to 18.79). Men were more likely than women to have coronary artery bypass grafting or percutaneous transluminal coronary angioplasty after a diagnosis of angina; older people were less likely to receive percutaneous transluminal coronary angioplasty. Acute myocardial infarction after a diagnosis of angina was associated with an increased risk of death from ischaemic heart disease and all cause mortality (8.84 (5.31 to 14.71) and 4.23 (2.78 to 6.43), respectively). Neither of the invasive cardiac procedures significantly reduced the subsequent risk of all cause mortality.

CONCLUSIONS

In this sample of people with incident angina from primary care, there were sex differences in survival and age and sex differences in the provision of revascularisation after a diagnosis. Acute myocardial infarction after a diagnosis of angina was strongly predictive of mortality. To minimise adverse outcomes, optimal preventive treatments should be used in patients with angina.

Patients Enrolled in Large Randomized Clinical Trials of Antiplatelet Treatment for Prevention After Transient Ischemic Attack or Ischemic Stroke Are Not Representative of Patients in Clinical Practice

Background and Purpose— Many randomized clinical trials have evaluated the benefit of long-term use of antiplatelet drugs in reducing the risk of new vascular events in patients with a recent transient ischemic attack or ischemic stroke. Evidence from these trials forms the basis for national and international guidelines for the management of nearly all such patients in clinical practice. However, abundant and strict enrollment criteria may limit the validity and the applicability of results of randomized clinical trials to clinical practice. We estimated the eligibility for participation in landmark trials of antiplatelet drugs of an unselected group of patients with stroke or transient ischemic attack from a national stroke survey.

Methods— Nine hundred seventy-two patients with transient ischemic attack or ischemic stroke were prospectively and consecutively enrolled in the Netherlands Stroke Survey. We applied 7 large antiplatelet trials’ enrollment criteria.

Results— In total, 886 patients were discharged alive and available for secondary prevention. Mean follow-up was 2.5 years. The annual rate of transient ischemic attack, stroke, or nonfatal myocardial infarction was 6.7%. The proportions of patients fulfilling the trial enrollment criteria ranged from 25% to 67%. Mortality was significantly higher in ineligible patients (27% to 41%) than in patients fulfilling enrollment criteria (16% to 20%). Rates of vascular events were not higher in trial-eligible patients than in ineligible patients.

Conclusions— Our data confirm that patients with ischemic attack and stroke enrolled in randomized clinical trials are only partially representative of patients in clinical practice. Use of less strict enrollment criteria could enhance “generalizability” and result in more efficient selection of patients for randomized clinical trials.

Multimorbidity and risk among patients with established cardiovascular disease: a cohort study

BACKGROUND

Most patients managed in primary care have more than one condition. Multimorbidity presents challenges for the patient and the clinician, not only in terms of the process of care, but also in terms of management and risk assessment.

AIM

To examine the effect of the presence of chronic kidney disease and diabetes on mortality and morbidity among patients with established cardiovascular disease.

DESIGN OF STUDY

Retrospective cohort study.

SETTING

Random selection of 35 general practices in the west of Ireland.

METHOD

A practice-based sample of 1609 patients with established cardiovascular disease was generated in 2000-2001 and followed for 5 years. The primary endpoint was death from any cause and the secondary endpoint was a cardiovascular composite endpoint that included death from a cardiovascular cause or any of the following cardiovascular events: myocardial infarction, heart failure, peripheral vascular disease, or stroke.

RESULTS

Risk of death from any cause was significantly increased in patients with increased multimorbidity (P<0.001), as was the risk of the cardiovascular composite endpoint (P<0.001). Patients with cardiovascular disease and diabetes had a similar survival pattern to those with cardiovascular disease and chronic kidney disease, but experienced more cardiovascular events.

CONCLUSION

Level of multimorbidity is an independent predictor of prognosis among patients with established cardiovascular disease. In such patients, the presence of chronic kidney disease carries a similar mortality risk to diabetes. Multimorbidity may be a useful factor in prioritising management of patients in the community with significant cardiovascular risk.

Selection bias in enrollment to a programme aimed at the secondary prevention of ischaemic heart disease in general practice: a cohort study

OBJECTIVE

To evaluate differences between adults who participated in a secondary prevention of ischaemic heart disease (IHD) programme and those who did not.

DESIGN

Population-based cohort study.

SETTING

A random selection of 12 Irish general practices.

PARTICIPANTS

A total of 493 adults with IHD identified in 2000/2001.

INTERVENTION

Medical records search and postal questionnaires in 2000/2001 and 2005/2006.

MAIN OUTCOME MEASURES

Differences in demographic characteristics and indicators of process of care and risk factor management between participants and non-participants.

RESULTS

Multiple logistic regression confirmed that female gender was associated with a reduced likelihood of participation in the secondary prevention programme [odds ratio (OR) 0.53 (95% CI: 0.32-0.87)], while an adequately controlled total cholesterol level was associated with an increased likelihood of enrollment [OR 1.82 (95% CI: 1.18-2.80)].

CONCLUSIONS

There is limited evidence that biases, which have been shown to affect participation in research, also affect participation in care programmes in everyday practice. A gender bias appears to have affected the enrollment of participants for the secondary preventive programme considered by this study, with enrollment favouring men with well-managed cholesterol. Reimbursement dependent upon patient adherence may incentivise the enrollment of adherent patients, although the influence of patient choice is unclear: the need to maintain records relating to patients who opt out of such interventions is thus highlighted.

Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial

BACKGROUND

Anticoagulants are more effective than antiplatelet agents at reducing stroke risk in patients with atrial fibrillation, but whether this benefit outweighs the increased risk of bleeding in elderly patients is unknown. We assessed whether warfarin reduced risk of major stroke, arterial embolism, or other intracranial haemorrhage compared with aspirin in elderly patients.

METHODS

973 patients aged 75 years or over (mean age 81.5 years, SD 4.2) with atrial fibrillation were recruited from primary care and randomly assigned to warfarin (target international normalised ratio 2-3) or aspirin (75 mg per day). Follow-up was for a mean of 2.7 years (SD 1.2). The primary endpoint was fatal or disabling stroke (ischaemic or haemorrhagic), intracranial haemorrhage, or clinically significant arterial embolism. Analysis was by intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN89345269.

FINDINGS

There were 24 primary events (21 strokes, two other intracranial haemorrhages, and one systemic embolus) in people assigned to warfarin and 48 primary events (44 strokes, one other intracranial haemorrhage, and three systemic emboli) in people assigned to aspirin (yearly risk 1.8%vs 3.8%, relative risk 0.48, 95% CI 0.28-0.80, p=0.003; absolute yearly risk reduction 2%, 95% CI 0.7-3.2). Yearly risk of extracranial haemorrhage was 1.4% (warfarin) versus 1.6% (aspirin) (relative risk 0.87, 0.43-1.73; absolute risk reduction 0.2%, -0.7 to 1.2).

INTERPRETATION

These data support the use of anticoagulation therapy for people aged over 75 who have atrial fibrillation, unless there are contraindications or the patient decides that the benefits are not worth the inconvenience.

Access to stroke care in England, Wales and Northern Ireland: the effect of age, gender and weekend admission

STUDY OBJECTIVES

To determine whether access to high-quality stroke care is affected by the age or gender of the patient or by weekend admission.

DESIGN

Data were collected as part of the National Sentinel Audit of stroke in 2004, both on the organisation of in-patient stroke care and the process of care to hospitals managing stroke patients.

SETTING

Two hundred and forty-six hospitals from England, Wales and Northern Ireland took part in the 2004 National Stroke Audit, a response rate of 100%. These sites audited te care of 8,718 patients. AUDIT TOOL: Royal College of Physicians Intercollegiate Working Party Stroke Audit Tool.

RESULTS

Overall standards of care for cases of stroke in England, Wales and Northern Ireland are low. Older patients are less likely to be treated in a stroke unit than younger patients (risk ratio comparing 85 + years with those <65 years 0.82 (95% CI 0.75-0.90). Seventy-one per cent of patients under 65 years were scanned within 24 h compared to 51% aged over 85 years. Older patients were also less likely than younger ones to receive secondary prevention and some aspects of rehabilitation, especially around higher functioning. Standards were consistently better for patients of all ages managed in stroke units compared to general wards. At weekends, patients were less likely to be admitted directly to a stroke unit (risk ratio 0.77 95% CI 0.69-0.86) and brain imaging was performed less often for older (85 + years) patients (weekday 56%, weekend 40%). There was little evidence of differences in standards of care between males and females.

CONCLUSION

There is clear evidence of an age effect on the delivery of stroke care in England, Wales, and Northern Ireland, with older patients being less likely to receive care in line with current clinical guidelines. Quality of acute care is also less good for patients admitted at weekends. No systematic evidence for sexism was identified.

The elephant in the room - healthy brains in later life, epidemiology and public health

The increasing age of the population around the world has meant that greater attention is being paid to disorders that mainly affect older people. In particular, work is focusing on ways to preserve the healthy brain and prevent dementia. Preventive studies are complex and must take into account not only simple approaches such as those used in risk and outcome studies, but also stage of life, survival and mortality, and population context before their effect can be assessed. This paper presents questions and areas which must be explored if the potential for prevention of dementia during brain ageing is to be properly understood.

[From evidence to recommendation influence of consensus processes on grades of recommendation-'against consensus'?]

Guidelines are not only sources of condensed evidence. They also contain graded recommendations that have been agreed upon in consensus procedures. Frequently there are discrepancies between the results of the critical appraisal of the evidence expressed in levels of evidence and the strength of the resulting recommendations. Unfortunately, the reasons for these discrepancies remain largely obscure and guideline users are therefore unable to comprehend this so-called 'upgrading' or 'downgrading', respectively. A consensus process consisting of several stages and a more detailed documentation could be a possible remedy. The present contribution is based on a lecture held at the 7th Annual Meeting of the DNEbM (German Network for Evidence-based Medicine) in Bochum in March 2006.

How to formulate research recommendations

“More research is needed” is a conclusion that fits most systematic reviews. But authors need to be more specific about what exactly is required